Exchange  from 

College  of  Medical  Evangelists 
Loma  Linda 


COLLEGE  OF   OSTEOPATHIC   PHYSICIANS 
AND  SURGEONS   •  LOS  ANGELES,  CALIFORNIA 


'" 


URES 


ON  THE 


DIAGNOSIS   AND  TREATMENT 


OF 


DISEASES  OF  THE  CHEST 


THROAT,  AND  NASAL  CAVITIES  • 


.*<  BY 

><  J- 

E;  FLETCHER    INGALS,  A.M.,    M.l). 

LECTURER  ON  DISEASES  OF  THE  CHEST  AND  PHYSICAL   DIAGNOSIS,  AND   ON   LARYNGOLOGY  IN  THI 

POST  GRADUATE  COURSE,  RUSH  MEDICAL  COLLEGE;  CLINICAL  PROFESSOR  OF  DISEASES 

OF  THE  THROAT  AND  CHEST,  WOMAN'S  MEDICAL  COLLEGE;  PHYSICIAN  AND 

SURGEON  FOR  DISEASES  OF  THE  THROAT  AND  CHEST,  CENTRAL 

FREE  DISPENSARY,  CHICAGO. 


With  One  Hundred  and  Thirty-five  Illustrations. 


NEW  YORK 

WILLIAM     WOOD     &     COM  B'AMK  T 
1 88 1 


COPYRIGHT,  1881,  BY 
WILLIAM  WOOD  &  COMPANY. 


STEAM    TRESS  OF 

H.  O.  A.  INDUSTRIAL  SCHOOL, 
*a?  &  i8g  E,  76™  ST. 


• 


PREFACE. 


These  lectures  are  designed  to  present  a  complete  ex- 
position of  the  subject  of  Physical  Diagnosis  so  far  as  it 
relates  to  diseases  of  the  Chest,  Throat,  and  Nasal 
Passages;  to  give  the  essential  symptoms  of  each  dis- 
ease; to  point  out  the  symptoms  and  signs  which  are  of 
most  value  in  a  differential  diagnosis;  and  to  outline 
briefly  the  proper  treatment  for  the  various  affections. 
The  anatomical  characteristics  and  the  causes  of  these 
diseases  have  been  pointed  out  wherever  they  are  of 
special  value  in  enabling  the  reader  to  understand  the 
physical  signs,  or  to  properly  apply  remedial  measures. 
When  these  lectures  were  delivered,  nothing  was  said 
about  treatment,  but  in  order  to  enhance  the  value  of 
this  work  to  both  physician  and  student,  I  have 
appended  to  the  consideration  of  the  diagnosis  of  each 
disease,  an  outline  of  the  treatment  which  I  have  found 
most  satisfactory.  In  so  doing,  I  have  not  even  men- 
tioned many  methods  of  treatment  of  more  or  less  value 
which  have  been  recommended  by  other  physicians. 

In  the  preparation  of  these  lectures  I  have  availed: 
myself  of  every  source  of  information  at  my  command,, 
and  I  hope  that  little  has  been  overlooked  which  would 
be  of  value  to  the  student  or  practitioner.  The  study  of 
this  subject  for  several  years,  in  connection  with  my  lec- 
tures, and  a  large  personal  experience  with  these  affec- 
tions have  enabled  me  to  discriminate  as  to  the  relative 
importance  of  different  signs  and  to  detect  numerous 
exceptions  to  the  general  rules.  These  exceptions,  some 


26726 


iv  PREFACE. 

of  which  are  extremely  rare,  are  of  little  importance  to 
the  general  practitioner,  and  the  study  of  them  is  a  pos- 
itive injury  to  the  student  unless  their  true  significance 
is  understood.  Matter  relating  to  them  has,  therefore, 
been  set  in  small  type,  so  that  it  may  be  omitted  until 
the  student  has  become  thoroughly  familiar  with  the  facts 
that  are  essential. 

The  nature  of  these  lectures  which  contain  informa- 
tion gathered  from  many  different  sources  by  study  and 
by  personal  observation,  and  the  fact  that  much  of  which 
they  treat  has  long  since  become  public  property,  renders 
it  impossible  for  me  in  every  instance  to  give  the  credit 
to  individual  authors  which  I  desire,  but  I  freely 
acknowledge  my  indebtedness  to  all  who  have  preceded 
me  in  this  field.  I  am  indebted  to  the  courtesy  of 
Doctors  J.  Solis  Cohen,  of  Philadelphia,  and  Lennox 
Browne  and  Morell  Mackenzie,  of  London,  for  permis- 
sion to  use  some  of  the  cuts  which  illustrate  their  works. 
I  take  special  pleasure  in  expressing  my  obligation  to 
my  clinical  assistants,  Doctors  Philip  Leach,  W.  H.  Tay- 
lor, and  J.  T.  Eggers,  for  valuable  aid  in  the  revision  of 
jny  notes. 

Messrs.  Sharp  &  Smith,  of  this  city,  have  kindly  fur- 
nished electrotypes  for  the  illustrations  of  instruments. 

E.  F.  I. 

1 88  Clark  Street, 
•CHICAGO,  November  isth,  1880. 


CONTENTS. 


PAGE 

LECTURE  I. — PHYSICAL  DIAGNOSIS r 

Regions;  Contents  of  regions.     Inspection.     Inspection  in  pleurisy. 

LECTURE  II 15 

Inspection  in:  Pulmonary  emphysema;  Pneumonia;  Phthisis;  Pneumothorax; 
Hydrothorax;  Pericarditis;  Hypertrophy  of  the  heart;  Tumors;  Membranous 
croup;  Bronchitis.  Palpation.  Vocal  fremitus;  Vocal  fremitus  in  various 
diseases;  Friction  and  rhonchial  fremitus;  Fluctuation.  Mensuration;  Instru- 
ments for.  Succussion. 

LECTURE  III 28 

Percussion;  Instruments  for;  Rules  for.     Resonance  in  health. 

LECTURE  IV 38 

Percussion  in  disease:  Exaggerated  resonance;  Dulness;  Flatness;  Tympa- 
nitic  resonance;  Vesiculo-tympanitic  resonance;  Amphoric  resonance;  Cracked- 
pot  resonance.  Plessigraph.  Auscultatory  percussion. 

LECTURE  V 46 

Auscultation:  History  of;  Instruments;  Physiological  action  of  the  respiratory 
organs.  Auscultation  in  health:  Vesicular  munnur;  Laryngeal  and  tracheal 
respiration;  Bronchial  respiration. 

LECTURE  VI .,    56 

Auscultation  in  disease:  Exaggerated  respiration;  Feeble  respiration;  Sup- 
pressed respiration;  Interrupted  respiration;  Interval  prolonged;  Expiration 
prolonged;  Rude  respiration;  Bronchial  respiration;  Cavernous  respiration; 
Broncho-cavernous  respiration;  Amphoric  respiration. 

LECTURE  VII ' 65 

Adventitious  sounds  :  dry  and  moist  rales — sonorous,  sibilant,  mucous,  sub- 
crepitant,  and  crepitant  rales;  Gurgles;  Mucous  click. 

LECTURE  VIII 73 

Vocal  sounds :  Feeble  vocal  resonance;  Exaggerated  vocal  resonance;  Bron- 
chophony;  ^gophony;  Pectoriloquy ;  Amphoric  voice.  \Vhisperresonanceand 
its  varieties.  Metallic  tinkling.  Tussive  signs;  Varieties  of  cough. 

LECTURE  IX — DIAGNOSIS  AND  TREATMENT  OF  PULMONARY  DISEASES 81 

Acute  pleurisy;  Subacute  pleurisy;  Chronic  pleurisy;  Circumscribed  pleu- 
risy; Pleurisy  of  the  apex;  Diaphragmatic  pleurisy;  Multilocular  pleurisy; 
Hydrothorax. 

LECTURE  X 98 

Pneumothorax  and  pneumo-hydrothorax;  Subacute,  acute,  and  chronic  bron- 
chitis; Capillary  bronchitis;  Plastic  bronchitis. 


yj  CONTENTS. 

PAGE- 
LECTURE  XI IZI 

Dilatation  of  the  bronchial  tubes;  Asthma;  Pulmonary  emphysema. 

LECTURE  XII ;••  I2° 

Pneumonia;  Lobar  and  lobular;  Typhoid  pneumonia;  Secondary  pneumonias. 

LECTURE  XIII • T33 

Pulmonary  hemorrhage;  Pulmonary  apoplexy;  Pulmonary  embolism  or  throm- 
bosis; Pulmonary  collapse;  Pulmonary  oedema;  Pulmonary  gangrene;  Tumors 
of  the  lungs;  Pulmonary  cancer;  Enlargement  of  the  bronchial  glands; 
Whooping  cough. 

LECTURE  XIV. H7 

Pulmonary  phthisis;  Fibroid  phthisis;  Miliary  or  acute  tuberculosis;  Infective 
phthisis;  Brown  induration  of  the  lungs;  Syphilitic  disease  of  the  lungs; 
Hydatids  of  the  lungs. 

LECTURE  XV. — THE  HEART  AND  AORTA 162 

Relations  of  the  heart  and  great  arteries;  Physiological  action  of  the  heart; 
Heart  sounds;  Rhythm  of  the  heart. 

LECTURE  XVI i?7 

Methods  of  cardiac  exploration,  inspection,  palpation,  percussion,  and  auscul- 
tation. 

LECTURE  XVII 179 

Superficial  and  deep-seated  cardiac  dulness  in  health  and  disease;  Causes 
of  the  heart-sounds;  Heart-sounds  in  disease. 

LECTURE  XVIII 188 

Cardiac  murmurs;  Areas  of  cardiac  murmurs;  Causes  of  endocardial  murmurs. 

LECTURE  XIX zoo 

Murmurs  continued — Anomalous  heart-sounds;  Subclavian  murmurs.  Venous 
signs :  Congestion  and  pulsation;  Collapse;  Venous  murmurs.  Sphygmo- 
graphic  tracings. 

LECTURE  XX. — DIAGNOSIS  AND  TREATMENT  OF  CARDIAC  DISEASES 212 

Pericarditis;  Pneumo-pericardium ;  Endocarditis;  Hypertrophy  of  the  heart; 
Hypertrophy  and  Dilatation  of  the  heart;  Dilatation  of  the  heart;  Asystolism. 

% 

LECTURE  XXI 225, 

Atrophy  of  the  heart;  Fatty  degeneration  of  the  heart;  Myocarditis;  Acute 
aneurism  of  the  heart;  Abscess  of  the  heart;  Rupture  of  the  heart;  Fibroid 
disease  of  the  heart;  Syphilitic  disease  of  the  heart;  Ulcerative  endocarditis; 
Valvular  disease  of  the  heart;  Morbus  cseruleus;  Functional  disease  of  the 
heart. 

LECTURE  XXII. — DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF  THE  AORTA.  237 
Aortitis;  Atheroma;  Aneurism  of  the  sinuses  of  Valsalva;  Aneurism  of  the 
thoracic  aorta;  Aneurism  of  the  arteria  innominata;  Aneurism  of  the  pulmo- 
nary artery;    Aneurism  of  the  descending  aorta;  Coarctation  of  the  aorta; 
Intra-thoracic  tumors. 

LECTURE  XXIII.— THE  THROAT  AND  NASAL  PASSAGES 254 

Examination  of  the  fauces;  Laryngoscopy  ;  Laryngoscope;  Reflectors,  etc. 


CONTENTS.  Vii 

PAGE 

LECTURE  XXIV 265 

The  laryngoscope  continued — Illuminating  apparatus;  Light  to  be  employed. 
Rhinoscope.  Rules  for  laryngoscopy. 

LECTURE  XXV 281 

Obstacles  to  laryngoscopy — Elongated  uvula,  Irritable  fauces,  Short  frsenum, 
Arching  of  the  tongue,  Enlarged  tonsils,  Pendent  epiglottis.  Infra-glottic 
laryngoscopy.  Rules  for  rhinoscopy.  Obstacles  to  rhinoscopy — Irritability  of 
the  tongue,  Elongated  uvula,  Irritability  of  the  fauces,  Closure  of  the  post- 
palatine  space. 

LECTURE  XXVI 290 

The  normal  larynx.    Vault  of  the  pharynx  and  nasal  cavities  in  health. 

LECTURE  XXVII. — DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF  THE  FAUCES.  305 
Acute  sore  throat;  Phlegmonous  sore  throat;  Erysipelatous  sore  throat;  Rheu- 
matic sore  throat;  Simple  membranous  sore  throat;  Acute   follicular  pharyn- 
gitis; Acute  follicular  glossitis  ;  Chronic  follicular  pharyngitis;  Scrofulous  sore 
throat;  Acute  tuberculous  sore  throat. 

LECTURE  XXVIII  317 

Diseases  of  the  fauces  continued — Diphtheria;  Acute  tonsillitis;  Chronic  ton- 
sillitis; Concretions  in  the  tonsils;  Foreign  bodies  in -the  fauces;  Retro- 
pharyngeal  abscess;  Neuroses  of  the  pharynx — Anaesthesia,  Hyperaesthesia, 
Paraesthesia,  Neuralgia,  Spasm;  Paralysis — Diphtheritic  paralysis,  Paralysis 
of  the  constrictors  of  the  pharynx,  Progressive  bulbar  paralysis.  Swallowing 
of  the  tongue;  Diseases  of  the  valeculae  and  pyriform  sinuses. 

LECTURE  XXIX. — DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF  THE  LARYNX.  330 
Acute  laryngitis;  Traumatic  laryngitis;  Chronic  laryngitis;  Phlebectasis  laryn- 
gea  ;  Trachoma  of  the  vocal  cords;  Croup;  Phlegmonous  laryngitis;  Erysi- 
pelatous laryngitis. 

LECTURE  XXX 347 

Abscess  of  larynx;  (Edema  of  the  larynx;  Tracheitis;  Chondritis  and  peri- 
chondritis  of  the  laryngeal  cartilages;  Tuberculous  laryngitis;  Syphilitic 
laryngitis;  Stenosis  of  larynx  and  trachea. 

LECTURE  XXXI 365 

Lupus  of  the  larynx;  Lepra;  Hypertrophy;  Secondary  diseases  of  the  larynx 
— Small-pox,  Measles,  Scarlatina.  Morbid  growths,  benign  and  malignant. 
Tracheal  tumors.  Involution  of  the  trachea;  Tracheocele.  Foreign  bodies 
in  the  larynx;  Foreign  bodies  in  the  trachea. 

LECTURE  XXXII 381 

Spasm  of  the  larynx;  Irritative  cough;  Spasmodic  cough;  Anaesthesia  of  the 
larynx;  Hyperaesthesia  of  the  larynx;  Motor  paralysis — Paralysis  of  the  thyro- 
epiglottic  and  ary-epiglottic  muscles;  Paralysis  of  the  crico-thyroid  muscles; 
Paralysis  of  the  thyro-arytenoid  muscles;  Bilateral  paralysis  of  the  lateral 
crico-arytenoid  muscles;  Unilateral  paralysis  of  the  lateral  crico-arytenoid 
muscle;  Paralysis  of  the  arytenoid  muscle;  Bilateral  paralysis  of  the  posterior 
crico-arytenoid  muscles;  Unilateral  paralysis  of  the  posterior  crico-arytenoid 
muscle;  Anchylosis  of  the  arytenoid  cartilages;  Atrophy  of  the  vocal  cords. 


viii  CONTENTS. 

PACK 

LECTURE  XXXIII. — DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF  THE  NASAL 

PASSAGES 397 

Hay  asthma;  Acute  coryza;  Chronic  coryza;  Adenoma  of  the  vault  of  the 
pharynx;  Submucous  infiltration  at  the  sides  of  the  vomer;  Distortion  of  the 
septum;  Thickening  of  the  septum;  Nasal  abscess;  Syphilitic  affections  of  the 
nares;  Stenosis  of  the  nasal  passages;  Foreign  bodies  in  the  nasal  passages; 
Nasal  tumors;  Neuroses  of  the  nasal  passages — Anosmia;  Hypersesthesia; 
Paralysis  of  the  nostrils. 

APPENDIX 41 

Various  formulae. 


PU  LMON  ARY     DISEASES.* 


LECTURE  I. 

PHYSICAL  DIAGNOSIS. 

In  the  course  of  lectures  upon  which  we  are  entering,  I  shall 
first  describe  to  you  the  methods  for  detecting  disease,  which 
are  based  upon  the  pathological  changes  in  the  organs  affected. 
Next  I  shall  point  out  the  characteristics  and  significance  of 
the  various  signs,  and  finally  I  shall  consider  the  diagnosis  and 
treatment  of  individual  diseases. 

The  term  physical  diagnosis  is  used  to  designate  these 
methods,  whether  used  in  the  examination  of  the  chest  or  in 
the  examination  of  any  other  part  of  the  body.  Some  of  these 
methods  are  in  use  by  all  classes  of  physicians,  no  matter  what 
the  disease;  but  as  it  is  in  the  exploration  of  the  chest  that 
such  methods  have  yielded  the  most  brilliant  results,  it  is  now 
customary  to  apply  the  term  physical  diagnosis  simply  to  the 
examination  of  the  thorax. 

It  is  in  this  limited  sense  that  1  shall  generally  use  it,  though 
it  will  also  be  applied  to  the  examination  of  the  upper  air- 
passages. 

The  principal  methods  of  physical  examination,  six  in  num- 
ber, are  named  :  Inspection,  Palpation,  Mensuration,  Succus- 
sion,  Percussion,  and  Auscultation.  Unfortunately  the  major- 
ity of  physicians  confine  themselves  to  one  of  these,  relying  for 
their  diagnosis  almost  exclusively  upon  auscultation.  It  will 
not  be  necessary  to  enlarge  upon  the  fallacy  of  this  course 

*  In  the  following  pages,  things  which  are  exceptional,  or  of  comparatively  little  im- 
portance, will  be  found  in  smaller  type,  which  the  student  is  advised  to  omit  until  he 
is  familiar  with  the  essentials.  In  the  tables  illustrating  the  differential  diagnosis  of 
diseases,  signs  common  to  both  are  omitted,  for  the  sake  of  making  the  distinction 
clearer. 

I 


PULMONARY   DISEASES. 

2 

when  I  tell  you  that  there  are  many  cases  in  which  it  will  be 
necessary  for  you  to  use  every  method  and  to  scrutinize  every 
symptom,  before  you  can  arrive  at  an  accurate  diagnosis. 

The  evidences  of  disease  which  these  methods  furnish  are 
known  as  signs  or  physical  signs. 

There  is  a  marked  difference  between  symptoms  and  signs. 
Symptoms,  which  are  chiefly  derived  from  the  statements  of 
the  patient,  may  be  called  presumptive  evidence  of  disease, 
while  signs  are  considered  positive  evidence. 

The  value  to  you  of  these  signs  will  depend  upon  your 
knowledge  of  the  alterations  which  produce  them. 

The  early  students  of  physical  diagnosis  noted  the  various 
characteristics  of  a  sign  accurately  and  located  it  upon  the 
surface  of  the  chest,  then  at  the  autopsy  they  sought  to  ascer- 
tain its  causes.  At  present  we  only  need  to  study  the  sign 
clinically,  for  its  causes  may  be  learned  from  our  text-books  ; 
however,  it  will  be  of  great  advantage  for  you  to  study  the 
signs  in  clinical  cases,  noting  their  location  and  their  various 
characteristics,  and  inspecting  at  the  autopsy,  whenever  possi- 
ble, the  lesions  which  caused  them. 

To  simplify  the  study  of  physical  diagnosis,  and  to  enable  us 
to  fix  accurately  in  our  minds  the  position  of  the  intra-thoracic 
organs,  the  chest  has  been  divided  into  a  number  of  artificial 
regions. 

These  regions  are  purely  arbitrary ;  consequently  you  will 
find  their  boundaries  vary  with  different  authors. 

Prof.  Da  Costa  divides  the  chest  into  four  regions :  the  ante- 
rior, the  posterior,  and  a  lateral  region  on  each  side ;  and  he 
subdivides  the  anterior  and  the  posterior  into  an  upper  and  a 
lower  region.  He  locates  signs  found  in  these  regions  by  cer- 
tain fixed  marks  which  may  be  found  on  the  surface  of  the 
chest.  For  instance,  anteriorly,  a  sign  may  be  located  in  a 
certain  intercostal  space,  or  beneath  a  rib  or  beneath  the  clavi- 
cle, at  a  given  distance  from  the  sternum.  Posteriorly,  a  sign 
may  be  located  in  a  similar  manner  with  reference  to  the 
spinous  processes,  or  to  the  angles  and  the  borders  of  the 
scapulae. 

This  division  is  well  enough  for  the  record  of  cases,  but  it 
does  not  aid  us  in  remembering  the  location  of  the  intra- 
thoracic  organs.  The  division  I  shall  adopt  is  similar  to  that 


PHYSICAL   DIAGNOSIS.  3 

quite  commonly  taught,  with  only  such  changes  as  make  it 
plainer  and  easier  to  be  remembered. 

While  learning  these  boundaries,  I  wish  you  also  to  fix  in 
your  minds  the  exact  position  of  the  intra-thoracic  organs. 

We  will  divide  the  chest  primarily  into  anterior,  posterior, 
and  lateral  regions,  and  these  we  will  subdivide  as  follows. 


FIG  i. — A,  Supra-clavicular  region.  B,  Clavicular  region,  c,  Infra-clavicular  re- 
gion. D,  Mammary  region.  E,  Infra-mammary  region.  F,  Upper  sternal  region. 
G,  Sternal  or  lower  sternal  region. 

The  wavy  lines  represent  the  borders  of  the  lungs  and  the  pulmonary  fissures.  The 
dotted  lines  correspond  to  the  outlines  of  the  various  organs,  viz.,  trachea,  aorta,  bron- 
chial tubes,  heart,  liver,  spleen,  and  stomach.  The  very  dark  shading  over  the  solid 
viscera  shows  the  normal  areas  of  flatness,  and  the  shading  next  lighter  over  the  upper 
part  of  the  liver  shows  the  hepatic  dulness.  The  black  rectangular  spots  near  the  third 
rib  correspond  to  the  position  of  the  valves  of  the  heart. 

Upon  the  anterior  surface  of  the  chest  on  either  side,  from 
above  downwards,  we  have  first  the  supra-clavicular  region, 
then  the  clavicular,  the  infra-clavicular,  and  still  farther  down 
the  mammary,  and  below  it  the  infra-mammary  ;  between  these 
two  lateral  halves  we  find  the  supra-sternal  and  the  sternal 
regions;  the  sternal  being  also  subdivided  into  the  superior- 
sternal  and  the  inferior-sternal. 


PULMONARY   DISEASES. 
4 

The  posterior  portion  of  the  chest,  on  each  side,  is  subdivided 
into  the  supra-scapular  and  the  scapular  regions,  between  these 
the  inter-scapular  region,  and  below  the  scapulas  the  infra- 
scapular  regions  (Fig.  2).  Laterally  we  have  the  axillary  and 
the  infra-axillary  regions. 

THE  SUPRA-CLAVICULAR  REGION  corresponds  to  that  portion 
of  the  pleural  cavity  which  extends  above  the  clavicles.  It  is 
triangular  in  form,  located  with  its  base  internal,  its  apex  ex- 
ternal. It  is  bounded  above  by  a  line  drawn  from  the  upper 
ring  of  the  trachea  outward  to  the  junction  of  the  middle  with 
the  external  third  of  the  clavicle. 


FIG.  2. — The  wavy  lines  correspond  to  the  borders  and  fissures  of  the  lungs.  The  dotted 
line  across  the  scapular  region  indicates  the  position  of  the  spine  of  the  scapula.  The 
dotted  lines  and  shaded  areas  in  the  infra-scapular  regions  indicate  the  position  of  the 
liver  and  spleen. 

The  inferior  boundary  of  this  region  corresponds  to  the 
upper  margin  of  the  inner  two  thirds  of  the  clavicle.  The  in- 
ternal boundary  corresponds  to  the  sterno-cleido-mastoid  mus- 
cle. This  region  contains,  on  either  side,  the  apex  of  the  lung, 
and  portions  of  the  subclavian  artery  and  vein. 

THE  CLAVICULAR  REGION  corresponds  to  the  inner  two  thirds 
of  the  clavicle  and  is  bounded  above  and  below  by  the  borders 
of  the  bone.  It  contains  lung  tissue  on  either  side.  Upon  the 
Tight  side  externally,  we  find  the  subclavian  artery,  and  at  the 
inner  extremity  the  arteria  innominata,  and  the  recurrent 


PHYSICAL   DIAGNOSIS. 


5 


laryngeal  nerve  as  it  passes  up  to  supply  the  muscles  of  the 
larynx.  Aneurisms  in  this  locality,  by  pressing  upon  this  nerve, 
give  rise  to  serious  symptoms  due  to  paralysis  or  spasm  of  the 
glottis.  Upon  the  left  side  at  the  inner  end  of  this  region,  we 
find  the  carotid  and  the  subclavian  arteries,  deeply  seated  and 
running  almost  at  right  angles  with  the  clavicle. 

THE  INFRA-CLAVICULAR  REGION  is  bounded  above  by  the 
clavicle,  internally  by  the  margin  of  the  sternum,  and  exter- 
nally by  a  straight  line  let  fall  from  the  outer  extremity  of  the 
clavicular  region,  and  passing  about  an  inch  externally  to  the 
nipple. 

It  is  bounded  below  by  the  lower  margin  of  the  third  rib. 

This  region  contains  lung  tissue  on  either  side.  On  the  right 
side,  close  to  the  border  of  the  sternum,  we  find  portions  of  the 
ascending  aorta  and  of  the  descending  vena  cava.  Just  be- 
neath the  second  costal  cartilage,  we  find  the  right  bronchus 
as  it  passes  into  the  right  lung.  Upon  the  left  side,  in  the 
second  intercostal  space,  close  to  the  margin  of  the  sternum, 
the  pulmonary  artery  is  located.  In  the  same  space  is  found 
the  left  bronchus,  which  inclines  more  downward  and  is  located 
lower  than  the  main  bronchus  on  the  opposite  side.  A  portion 
of  the  base  of  the  heart  occupies  the  internal  inferior  angle  of 
this  region. 

THE  MAMMARY  REGION,  which  lies  immediately  below  the 
preceding,  is  bounded  internally  by  the  margin  of  the  sternum, 
externally  by  a  continuation  of  the  line  which  bounds  the  infra- 
clavicular  region,  and  inferiorly  by  the  lower  margin  of  the 
sixth  rib.  You  will  easily  remember  the  boundaries  of  the 
infra-clavicular  and  the  mammary  regions,  by  recollecting  that 
we  have  three  ribs  in  each.  The  inferior  border  of  the  third 
rib  forms  the  lower  boundary  of  the  upper  region  and  the 
lower  margin  of  the  sixth  rib  bounds  the  lower  region  infe- 
riorly. 

This  region  contains  lung  tissue  on  both  sides.  On  the  right 
side,  the  thin  margin  of  the  lung,  which  overlaps  the  liver, 
reaches  to  the  sixth  interspace  and  extends  even  lower  in  full 
inspiration. 

Deeper  seated  we  find  the  upper  convex  surface  of  the  liver, 
carrying  the  diaphragm  above  it,  as  high  as  the  fourth  inter- 
costal space.  The  nipple  is  usually  located  in  the  fourth  inter- 


6  PULMONARY  DISEASES. 

costal  space  ;  therefore,  we  expect  to  find  the  upper  border  of 
the  liver  beneath  it.  A  small  portion  both  of  the  right  auricle 
and  of  the  right  ventricle  extends  into  this  region. 

In  the  upper  part  of  the  left  mammary  region,  the  lung  tissue 
is  in  front  as  low  as  the  fourth  rib.  At  this  level,  the  border  of 
the  lung  passes  outward  and  downward  to  the  fifth  rib,  leaving 
between  it  and  the  median  line,  a  triangular  space  in  which 
the  heart  and  its  investing  membrane  are  superficial. 

THE  INFRA-MAMMARY  REGION  is  bounded  externally  by  a  con- 
tinuation of  the  outer  boundary  of  the  mammary  region  ;  above 
by  the  lower  margin  of  the  sixth  rib,  and  internally  and  infe- 
riorly  by  the  margin  of  the  sternum  and  by  the  lower  borders 
of  the  false  ribs.  This  region  contains,  on  the  right  side,  the 
liver,  and  occasionally  the  inferior  margin  of  the  lung  during 
full  inspiration. 

On  the  left  side,  near  the  sternum,  we  find  a  portion  of  the 
left  lobe  of  the  liver;  a  little  farther  outward  near  the  middle 
of  the  region,  we  have  the  stomach,  and  in  the  outer  third  is  a 
portion  of  the  spleen.  The  stomach  and  the  spleen  usually 
extend  as  high  as  the  sixth  rib. 

The  mammillary  or  nipple  line  is  a  vertical  line  drawn  through 
the  nipple  which,  according  to  some  authors,  forms  the  external 
boundary  of  the  infra-clavicular,  mammary^and  infra-mammary 
regions. 

The  regions  between  the  lateral  halves  of  the  anterior  part 
of  the  chest  are  three  in  number.  The  first  of  these  from 
above  downward,  is  the 

SUPRA-STERNAL  REGION.  It  is  bounded  inferiorly  by  the  up- 
per end  of  the  sternum,  or  inter-clavicular  notch  ;  laterally  by 
the  sterno-cleido-mastoid  muscles,  and  above  by  the  first  ring 
of  the  trachea.  The  most  important  organs  in  this  region  are 
the  trachea  and  the  thyroid  gland,  the  lobes  of  which  lie  on  each 
side  of  the  trachea,  and  are  connected  by  the  isthmus  in  the 
upper  part  of  this  region.  Here  are  also  found  certain  small 
veins  and  arteries  which  are  of  interest  to  the  surgeon. 

In  the  lower  right  angle  of  this  region,  the  innominate  artery 
is  found,  and  in  the  inter-clavicular  notch  we  can  frequently 
feel  the  arch  of  the  aorta.  Beneath  this  region  we  have  the 

SUPERIOR  STERNAL  REGION  which  is  bounded  below  by  a 
line  connecting  the  lower  margins  of  the  third  ribs,  and  laterally 


PHYSICAL   DIAGNOSIS.  7 

by  the  borders  of  the  bone.  This  region  contains  lung  tissue. 
Superficially,  the  inner  or  anterior  margin  of  each  lung  reaches 
the  median  line.  Deeper,  we  find  the  descending  vena  cava, 
the  ascending,  transverse,  and  a  part  of  the  descending  portion 
of  the  arch  of  the  aorta,  and  at  the  left  a  portion  of  the 
pulmonary  artery.  At  a  point  opposite  the  junction  of  the 
second  costal  cartilages  with  the  sternum,  is  the  bifurcation  of 
the  trachea. 

THE  INFERIOR  STERNAL  REGION,  known  also  as  the  sternal 
region,  has  for  its  boundaries  the  borders  of  all  that  portion  of 
the  sternum  lying  below  the  third  ribs.  In  it  the  anterior  margin 
of  the  right  lung  corresponds  to  the  median  line,  and  is  superfi- 
cially situated.  But  the  corresponding  margin  of  the  left  lung 
recedes  from  the  median  line  at  the  level  of  the  fourth  rib,  anc1 
passes  outward  and  downward,  leaving  a  triangular  space  be- 
tween it  and  the  margin  of  the  right  lung.  In  this  space  the 
right  ventricle  of  the  heart  is  superficial.  In  the  upper  part  of 
this  region  we  find  a  large  portion  of  the  right  auricle.  Near 
its  upper  border  we  find  also  the  origin  both  of  the  aorta  and 
of  the  pulmonary  artery.  The  portions  of  the  left  side  of  the 
heart  which  present  anteriorly  lie  to  the  left  of  this  region. 

In  this  region  we  find  portions  of  the  four  sets  of  valves 
which  guard  the  orifices  of  the  heart  (Fig.  i).  At  the  left 
edge  of  the  sternum,  under  the  third  rib,  are  the  pulmonary 
valves;  a  trifle  lower,  beneath  the  centre  of  the  sternum,  are 
located  the  aortic  valves  ;  lower  down,  at  its  left  border  in  the 
third  intercostal  space,  we  find  the  mitral  valves.  We  locate 
the  tricuspid  valves  beneath  the  middle  of  the  sternum  on  a 
line  with  the  fourth  costo-sternal  articulation. 

These  valves  lie  so  closely  together  that  a  circle  scarcely 
more  than  an  inch  in  diameter  will  include  all  of  them,  and  a 
circle  of  half  that  diameter  will  embrace  a  portion  of  each. 

At  the  lower  part  of  this  region,  we  have  a  portion  of  the 
liver  and  of  the  attachment  of  the  pericardium  to  the  dia- 
phragm. 

The  niL'sosternal  line  is  an  imaginary  line  passing  down  the 
centre  of  the  sternum. 

The  parastcrnal  lines  correspond  on  each  side  to  the  borders 
of  the  sternum. 

Posteriorly  we  have  the  supra-scapular  and  the  scapular  re- 


g  PULMONARY    DISEASES. 

gions,  extending  from  the  second  to  the  seventh  rib  and  corre- 
sponding very  nearly  to  the  outlines  of  the  scapula,  when  the 
patient's  arms  are  hanging  loosely  by  his  side  (Fig.  2). 

THE  SUPRA-SCAPULAR  REGION  corresponds  to  the  supra-spi- 
nous  fossa. 

THE  SCAPULAR  REGION  corresponds  to  the  infra-spinous 
fossa.  These  regions  are  occupied  by  lung  tissue. 

THE  INTER-SCAPULAR  REGION  on  each  side  lies  between  the 
border  of  the  scapula  and  the  spinous  processes  of  the  verte- 
brae, and  extends  from  the  level  of  the  second  dorsal  vertebra 
to  the  level  of  the  seventh.  These  regions  contain  lung  sub- 
stance, the  main  bronchi,  and  the  bronchial  glands.  The  de- 
scending aorta  runs  along  the  left  of  the  spinal  column,  beside 
the  oesophagus.  The  trachea  bifurcates  opposite  the  third 
dorsal  vertebra.  In  these  and  in  the  two  preceding  regions,  the 
chest  walls  are  very  thick. 

THE  INFRA-SCAPULAR  REGION  is  bounded  internally  by  the 
spinous  processes  of  the  vertebras  ;  externally  by  a  perpendicu- 
lar line  let  fall  from  the  inferior  angle  of  the  scapula ;  above  by 
the  lower  margin  of  the  scapular  and  inter-scapular  regions, 
which  corresponds  to  the  seventh  rib ;  and  below  by  the  infe- 
rior margin  of  the  false  ribs.  This  region  contains  lung  tissue 
on  either  side,  extending  to  the  tenth  or  to  the  eleventh  rib. 
On  the  right  side,  below  the  margin  of  the  lung,  we  have  the 
liver.  On  the  left  side,  the  intestines  are  superficial  near  the 
middle  portion  of  the  region,  and  externally  we  find  the  spleen 
(Fig.  2).  The  kidneys  are  located  near  the  spinal  column  on 
either  side.  The  left  kidney  extends  an  inch  higher  than  the 
right,  and  its  upper  extremity  is  frequently  found  in  this  re- 
gion. 

LATERALLY  we  have  two  regions,  the  axillary  and  the'  infra- 
axillary. 

THE  AXILLARY  is  bounded  below  by  a  line  drawn  from  the 
lower  margin  of  the  mammary  region  backward  to  the  inferior 
angle  of  the  scapula ;  above  by  the  axilla  ;  in  front  by  the  outer 
boundaries  of  the  infra-clavicular  and  the  mammary  regions, 
and  posteriorly  by  the  axillary  border  of  the  scapula.  This 
region  contains  lung  tissue  on  each  side  and,  deeply  seated,  the 
main  bronchi. 

THE  INFRA-AXILLARY  REGION.— Below  this  we  have  the  infra- 


INSPECTION.  g 

axillary  region.  It  is  bounded  posteriorly,  by  the  outer  mar- 
gin of  the  infra-scapular  region  ;  anteriorly,  by  the  external 
margin  of  the  infra-mammary  region  ;  below,  by  the  margin  of 
the  false  ribs.  On  either  side,  we  find  the  lower  border  of  the 
lungs  running  from  near  the  upper  anterior  angle  of  this  region 
downward  and  backward.  Below  this,  on  the  right  the  liver, 
and  on  the  left  the  spleen,  and  a  portion  of  the  stomach,  are 
superficial. 

Pulmonary  fissures. — At  a  point  about  three  inches  below  the 
apex  of  the  lung,  which  corresponds  very  nearly  to  the  inner 
end  of  the  spine  of  the  scapula,  we  find  the  beginning  of  the 
pulmonary  fissures  which  separate  the  upper  from  the  lower 
lobes.  These  fissures  run  obliquely  downward  and  forward, 
the  one  on  the  left  side  coming  to  the  anterior  border  of  the 
lung,  beneath  the  fourth  intercostal  space  (Figs,  i  and  2). 

It  is  a  common  error  with  students  to  suppose  that  the  inter- 
lobar  fissures  run  in  the  opposite  direction,  that  is,  downward 
and  backward  from  the  upper  part  of  the  anterior  margin  of 
the  lung. 

On  the  right  side  the  fissure  commences  at  the  same  level 
and  reaches  the  anterior  margin  of  the  lung  near  the  fourth 
costal  cartilage.  At  a  point  on  this  fissure,  four  or  five  inches 
from  the  sternum,  we  find  the  commencement  of  another  fis- 
sure, which  passes  downward  and  inward  to  the  margin  of  the 
lung  on  a  level  with  the  fifth  intercostal  space.  By  this  fissure 
a  small  triangular  portion  is  cut  off  from  the  upper  part  of  the 
lower  lobe  to  form  the  middle  lobe  of  the  right  lung.  The 
positions  of  these  fissures  necessarily  change  considerably  with 
inspiration  and  expiration. 

INSPECTION. 

By  inspection  we  learn  the  general  appearance  of  the  pa- 
tient, the  color  of  the  integument,  the  presence  or  absence  of 
subcutaneous  emphysema,  oedema,  or  tumors  ;  and  the  size, 
form,  and  movements  of  the  chest. 

Whatever  method  of  physical  diagnosis  you  pursue,  it  is 
necessary,  first,  to  be  familiar  with  the  healthy  conditions  which 
it  would  reveal.  Therefore  I  wish  to  call  your  attention  to  the 
aspect  of  a  healthy  chest. 


I0  PULMONARY   DISEASES. 

It  has  a  generally  rounded  or  convex  appearance  ;  the  shoul- 
ders are  level,  the  clavicles,  horizontal,  and  the  two  sides  are 
almost  perfectly  symmetrical ;  however,  in  many  cases  more  or 
less  depression  will  be  observed  in  the  supra-clavicular  and 
infra-clavicular  regions,  and  not  infrequently  the  pectoral  mus- 
cles are  better  developed  on  one  side  than  on  the  other. 

Considerable  difference  in  the  form  and  in  the  movements 
of  the  chest  exists  in  persons  of  different  ages  and  sexes.  In 
women  the  upper  portion  is  more  prominent  than  in  men. 
The  inspiratory  movements  vary  accordingly,  being  more 
marked  at  the  upper  part  in  women,  at  the  lower  part  in  men. 
In  children  of  either  sex,  the  chest  walls  often  hardly  move  at 
all ;  and  the  respiration  seems  to  be  performed  by  the  abdomi- 
nal muscles. 

This  disparity  is  most  conspicuous  in  rapid  respiration. 

The  respiration  in  these  three  localities  gives  the  names 
superior-costal,  inferior-costal,  and  abdominal  breathing.  In 
men  a  deep  furrow  just  below  the  fifth  rib  marks  the  lower 
border  of  the  pectoralis  major  muscle.  At  the  border  of  the 
sternum,  about  an  inch  below  the  clavicle,  we  often  notice 
rounded  prominences  about  an  inch  in  diameter,  which  mark 
the  position  of  the  second  costal  cartilages.  These  are  fre- 
quently mistaken  by  students  for  abnormal  swellings.  In  some 
patients  the  ribs  and  the  intercostal  spaces  are  very  distinct, 
while  in  others  they  are  hidden  by  adipose  tissue.  The 
obliquity  of  the  inferior  ribs  varies  greatly  in  different  indi- 
viduals. 

In  the  fifth  intercostal  space,  about  two  inches  to  the  left  of 
the  sternum,  we  observe  the  impulse  of  the  chest-walls  caused 
by  the  apex  beat  of  the  heart. 

In  health,  the  respiratory  movements  are  repeated  sixteen  or 
twenty  times  a  minute  in  adults,  and  from  twenty  to  twenty- 
five  or  even  thirty  times  in  children. 

Occasionally  we  find  local  bulging  or  depression,  independ- 
ent of  disease  of  the  internal  organs.  The  prominent  sternum 
known  as  pigeon  breast,  usually  due  to  violent  cough,  or  ob- 
structed respiration,  as  from  catarrh  or  enlarged  tonsils  in 
childhood  ;  the  pear-shaped  chest  due  to  rachitis,  and  the  long, 
narrow  and  flat  chest,  which  often  results  from  rapid  growth, 
are  all  found  independent  of  intra-thoracic  disease  (Fig.  3). 


INSPECTION  1 1 

There  is  often  bulging  of  the  prascordial  region,  especially 
in  children.  I  have  seen  deep  depressions  of  the  lower  sternal 
region,  and  of  the  ribs  in  rare  instances,  in  healthy  individuals. 
I  have  here  a  cast  taken  from  life,  which  shows  a  depression  of 
the  lower  sternal  region  from  an  inch  and  a  half  to  two  inches 
in  depth ;  yet  the  individual  from  whom  it  was  taken  enjoyed 
perfect  health. 

Most  deviations  from  symmetry  in  the  two  sides  are  due  to 
slight  curvatures  of  the  spinal  column.  In  the  examination  of 
a  large  number  of  patients,  not  more  than  one  in  seven  will 
be  found  with  a  perfectly  symmetrical  chest. 


FIG.  3. — Transverse  outline  of  chest  (Thompson). 

The  movements  of  the  chest  are  altered  considerably,  irre- 
spective of  pulmonary  or  cardiac  disease.  In  health,  the  res- 
piratory movements  are  readily  accelerated  by  active  exercise, 
and  in  hysterical  patients  they  are  nearly  always  rapid  and 
superficial,  being  confined  mostly  to  the  upper  part  of  the 
chest.  In  persons  suffering  from  some  diseases  of  the  brain, 
the  respiratory  movements  become  slower  and  slower  until 
they  may  not  exceed  three  or  four  per  minute.  In  hemiplegia 
the  respiratory  movements  are  incomplete  or  wanting,  on  the 
affected  side  of  the  chest. 

Pregnancy,  ascites,  or  large  abdominal  tumors,  cause  pres- 
sure on  the  diaphragm,  and  consequent  interference  with 


I2  PULMONARY   DISEASES. 

respiration.  The  pain  of  peritonitis  compels  the  patient  to  re- 
strain the  movements  of  the  abdominal  muscles,  and  thus  con- 
fines the  respiratory  movements  to  the  chest,  and  renders  them 
deficient,  and  consequently  more  frequent. 

Among  the  first  signs  which  we  will  often  notice  on  inspect- 
ing a  patient  with  disease  of  the  intra-thoracic  organs  are  pal- 
lor, cyanosis,  icterus,  pityriasis,  dropsy,  and  subcutaneous 
emphysema. 

Pallor  of  the  surface  and  emaciation  are  seen  in  chronic 
pulmonary  disease.  Pallor  also  results  from  fatty  degenera- 
tion of  the  heart,  and,  in  some  cases,  from  mitral  disease. 

Cyanosis  more  or  less  marked  indicates  incomplete  oxida- 
tion of  the  blood,  due  to  obstruction  of  the  air  passages  or  to 
diminution  of  breathing  surface ;  also  to  affections  of  the  heart, 
such  as  congenital  malformations  or  valvular  disease.  Occa- 
sionally this  sign  results  from  interference  with  the  descent  of 
the  diaphragm  by  disease  of  the  abdominal  organs. 

Icterus  is  found  in  bilious  pneumonia  and  in  the  later  stages 
of  those  cardiac  diseases  which  cause  congestion  of  the  portal 
circulation. 

Pityriasis  is  often  found  with  phthisis  pulmonalis,  but  it 
also  occurs  with  other  diseases,  and  sometimes  even  in  ap- 
parently healthy  individuals. 

Dropsy  due  to  recent  renal  disease  usually  shows  itself  first 
in  the  lower  eyelids,  and  subsequently  disappears  from  this  lo- 
cality, to  appear  in  the  lower  limbs,  and  in  the  backs  of  the 
hands.  Dropsy  due  to  cardiac  disease  usually  appears  first 
over  the  instep,  and  gradually  extends  upward,  involving  the 
limbs,  trunk,  and  serous  cavities. 

Subcutaneous  emphysema  may  be  caused  by  internal  or  exter- 
nal injuries  of  the  larynx,  of  the  trachea,  or  of  the  lungs.  Air 
escaping  from  the  larynx  or  the  trachea  causes  emphysema  in 
the  region  of  the  throat.  Rupture  of  the  air  cells  from  over- 
distention,  as  in  croup,  diphtheritis  of  the  larynx,  whooping 
cough,  bronchitis  in  children,  and  emphysema  in  the  aged, 
causes  subcutaneous  emphysema,  which  appears  first  in  the 
areolar  tissue  of  the  neck,  and  subsequently  extends  to  the 
chest.  The  air  in  these  cases  finds  its  way  into  the  mediasti- 
num, and  thence  to  the  neck.  Subcutaneous  emphysema  from 
external  injury  appears  first  on  the  chest. 


INSPECTION.  !3 

Alterations  in  the  form  and  in  the  movements  of  the  chest 
may  be  most  advantageously  studied  when  grouped  together 
as  they  occur  in  different  thoracic  diseases. 

Pleurisy. — First,  let  us  consider  the  modifications  found  in 
pleurisy.  This  disease  is  divided  into  three  stages  :  first,  a  dry 
stage,  in  which  the  serous  membrane  at  first  becomes  dry  from 
diminution  of  its  natural  secretion,  and  subsequently  becomes 
coated  with  exudation. 

Second,  a  stage  in  which  liquid  effusion  is  found  in  the  pleu- 
ral  sac ;  and  third,  the  stage  of  resolution,  during  which  the 
fluid  is  absorbed.  In  the  first  stage,  the  patient,  if  in  bed,  will 
usually  be  found  resting  upon  the  sound  side. 

In  a  few  <  instances,  especially  with  children,  the  patient's  efforts  to  restrain  the 
movements  of  the  affected  side  of  the  chest  give  rise  to  temporary  curvature  of  the 
spine  towards  the  affected  side. 

In  this  stage  the  respiratory  movements  are  rapid,  short 
and  catching,  as  the  result  of  the  patient's  efforts  to  restrain 
the  movements,  and  thus  avoid  the  pain  incident  to  the  friction 
of  the  inflamed  pleuritic  surfaces. 

This  sign,  although  nearly  always  present,  is  not  diagnostic 
of  pleurisy  ;  for  in  intercostal  neuralgia  and  in  pleurodynia, 
you  may  find  similar  respiratory  movements. 

In  the  second  stage,  the  decubitus  will  be  upon  the  affected 
side.  If  there  is  a  considerable  amount  of  fluid,  movements 
of  the  affected  side  will  be  diminished,  and  the  intercostal  de- 
pressions will  be  less  marked  than  in  health. 

The  impulse  of  the  heart  will  be  more  or  less  displaced  to 
the  right  or  to  the  left,  according  as  the  left  or  the  right  pleura 
is  distended.  We  notice  also  an  apparent  increase  in  the  size 
of  the  affected  side,  but  a  quantity  of  fluid  sufficient  to  dilate 
the  side  of  the  chest  is  exceptional  in  acute  pleurisy. 

In  the  third  stage,  the  signs  of  the  second  stage  gradually 
subside,  the  movements  of  the  chest  return,  the  intercostal 
spaces  regain  their  natural  appearance,  and  the  heart  gravi- 
tates to  its  normal  position. 

Sub-acute  pleurisy  is  characterized  by  mildness  of  the  symp- 
toms and  by  the  exudation  of  an  excessive  amount  of  serum. 
Its  first  stage  is  seldom  observed.  Subsequently,  the  signs  are 
the  same  as  those  of  acute  pleurisy,  with  excessive  exudation. 


I4  PULMONARY   DISEASES. 

Chronic  pleurisy  is  a  term  which  is  occasionally  applied  to 
the  last-mentioned  disease,  but  it  is  more  generally  used  to 
•designate  that  form  of  pleurisy  known  as  empyema,  in  which 
there  is  a  collection  of  pus  in  the  pleural  cavity.  The  signs  of 
this  variety,  on  inspection,  do  not  differ  from  those  already 
mentioned.  In  chronic  pleurisy,  particularly  in  the  suppura- 
tive  variety,  the  elasticity  of  the  lung  is  impaired  by  long  com- 
pression, so  that  it  cannot  regain  its  original  volume  when  ab- 
sorption or  evacuation  of  the  liquid  takes  place,  and  con- 
sequently contraction  of  the  chest  results.  The  affected  side 
becomes  flattened,  especially  at  its  lower  part ;  and  the  shoul- 
der is  depressed.  The  nipple  is  also  depressed,  and  is  found 
nearer  the  median  line  than  on  the  sound  side  ;  the  inner 
border  of  the  scapula  projects  like  a  wing,  and  the  dimensions 
of  the  affected  side  are  reduced.  Often  there  is  a  lateral 
curvature  of  the  spine,  the  convexity  being  directed  toward 
the  sound  side,  excepting  in  rare  cases,  when  the  convexity 
may  be  found  in  the  opposite  direction. 

This  phenomenon  is  due  to  the  dorsal  muscles  of  the  sound  side  being  no  longer 
counterbalanced  by  those  of  the  affected  side.  The  latter  soon  become  paralyzed 
from  the  persistent  pressure.  The  ribs  are  drawn  downward  toward  the  pelvis,  and  the 
intercostal  spaces  are  nearly  or  completely  obliterated. 

Respiratory  movements  of  the  affected  side  are  limited  in 
proportion  to  the  deficient  expansion  of  the  lung. 


LECTURE     II. 

INSPECTION     CONTINUED— PALPATION,     MENSU- 
RATION,  AND    SUCCUSSION. 

In  pulmonary  emphysema,  on  first  sight  of  the  patient,  we 
notice  a  dusky  hue  of  the  countenance,  and  often  a  sunken 
condition  of  the  cheeks,  with  marked  general  emaciation  and 
more  or  less  turgescence  of  the  superficial  veins  of  the  neck  and 
upper  extremities.  There  is  elevation  and  drawing  forward  of 
the  shoulders,  with  anterior  curvature  of  the  spine,  giving  the 
patient  the  stooping  appearance  of  old  age.  though  he  may 
still  be  young.  The  nostrils  dilate  in  inspiration,  and  there  is 
a  peculiar  drawing  downward  of  the  corners  of  the  mouth. 

When  we  come  to  inspect  the  chest,  a  peculiar  form,  known 
as  the  "  barrel-shaped  chest,"  will  generally  be  seen.  In  this 
condition,  the  antero-posterior  diameter  of  the  chest  is  in- 
creased (Fig.  3,  page  1 1),  its  surface  is  rounded,  and  the  upper 
anterior  portion  stands  out  considerably  beyond  its  normal 
plane.  Laterally,  the  diameter  of  the  chest  is  diminished,  and 
ite  inferior  portion,  in  the  region  of  the  false  ribs,  is  more  or 
less  retracted.  The  elevation  and  the  drawing  forward  of  the 
shoulders  cause  the  neck  to  appear  considerably  shorter  than 
usual.  The  scaleni  and  the  sterno-cleido-mastoid  muscles  are 
hypertrophied  and  prominent,  so  that  they  stand  out  like  tense 
cords.  This  results  from  the  excessive  inspiratory  efforts, 
which  call  into  greater  activity  the  muscles  which  elevate  and 
fix  the  anterior  and  upper  part  of  the  thorax. 

The  patient  has  comparatively  little  difficulty  in  inspiration, 
but,  as  has  been  aptly  said,  "  His  whole  aim  in  life  seems  to  be 
to  get  air  out  of  his  chest." 

Inspiration  is  short  and  quick,  but  it  is  followed  by  pro- 
longed and  labored  expiration.  With  the  inspiratory  move- 
ments of  the  chest,  the  anterior  and  superior  portions  are  lifted 
as  though  they  were  composed  of  a  single  bone,  and  there  is 
apparently  no  anterior  or  lateral  expansion  of  the  chest-walls, 


j5  PULMONARY   DISEASES. 

because  the  ribs  are  already  rotated  as  far  as  their  articulation 
with  the  spinal  column  will  permit  The  ribs  have  less  obliq- 
uity, and  they  form  with  the  costal  cartilages  more  obtuse 
angles  than  in  the  normal  chest. 

The  intercostal  spaces  at  the  upper  part  of  the  chest  are  no- 
ticed to  be  much  wider  than  usual,  but  at  the  lower,  lateral 
portion  of  the  chest,  the  ribs  are  closer  together  than  in  the 
normal  condition,  and  thus  the  spaces  between  them  are  some- 
times obliterated. 

With  inspiration,  the  movements  of  the  lower  part  of  the 
chest  are  reversed,  so  that  instead  of  lateral  expansion,  there  is, 
very  generally,  retraction  of  the  inferior  ribs,  if  the  case  is 
well  marked.  This  falling  in  of  the  ribs  and  of  the  soft  parts  of 
the  thoracic  walls  is  not  noticed  if  the  disease  is  slight,  but  as 
the  case  progresses  it  may  be  seen  :  first,  in  the  supra-clavic- 
ular and  supra-sternal  regions,  then  just  below  the  clavicles 
and  about  the  same  time  in  the  lower  portion  of  the  chest. 
Sometimes  we  meet  with  local  emphysema,  where  a  single  lung 
or  only  one  of  its  lobes  is  affected.  In  such  instances,  \ve  notice 
local  prominence,  or  bulging  with  loss  of  motion,  in  the  cor- 
responding portion  of  the  thoracic  walls. 

In  extreme  emphysema,  the  anterior  margin  of  the  left  lung 
overlaps  the  heart  to  such  an  extent  that  the  apex  cannot  strike 
the  chest-wall,  and  therefore  no  impulse  can  be  seen.  In 
milder  cases,  the  impulse  may  be  seen  closer  to  the  sternufn 
than  in  health. 

In  Pneumonia,  upon  first  glancing  at  the  patient,  we  generally 
notice  a  dusky  flush  of  the  cheek  and  accelerated  respiratory 
movements.  Upon  inspection  of  the  chest,  we  will  observe 
diminished  motion  over  the  diseased  organ.  This  loss  of  mo- 
tion may  be  marked,  but  it  is  seldom  or  never  complete. 
Usually,  these  are  the  onl^-  signs  which  inspection  furnishes  in 
this  disease. 

In  Pulmonary  Phthisis,  the  signs  obtained  by  inspection  are 
of  considerable  value.  If  the  case  is  advanced,  the  portion  of 
the  chest-wall  covering  the  diseased  lung  will  be  found  de- 
pressed, and  its  movements  will  be  restricted.  This  depres- 
sion and  loss  of  movement  in  phthisis  is  more  apt  to  occur  at 
the  apex,  and,  contrary  to  the  general  belief,  it  is  quite  as  likely 
to  be  found  upon  the  right  as  upon  the  left  side.  These  phe- 


INSPECTION.  ly 

nomena  are  due  to  local  shrinkage  and  to  loss  of  elasticity  of 
the  lung-. 

In  Pncumothorax,  in  which  condition  the  pleural  sac  is  more 
or  less  filled  with  gas  or  air,  the  signs  obtained  by  inspection 
are  distention  of  the  chest,  proportionate  to  the  tension  of  the 
air  or  gas  in  the  pleural  sac,  and  a  corresponding  loss  of  mo- 
tion. If  the  amount  of  air  or  gas  is^  small,  the  distention  may 
scarcely  be  perceptible,  and  fair  motion  may  remain  ;  but  when 
the  sac  is  distended,  the  lower  ribs  do  not  move,  the  side  is  ex- 
panded to  its  utmost  extent,  and  the  intercostal  spaces  are 
prominent  in  the  lower  part  of  the  chest,  as  in  sub-acute  pleurisy. 

Exceptional. — In  some  rare  cases  of  this  disease,  the  upper  portion  of  the  affected 
side  seems  to  move  more  than  the  corresponding  part  of  the  sound  side. 

This  is  due  to  the  extreme  efforts  on  inspiration  by  which  the  superior  ribs  are  lifted 
directly  upwards  as  in  emphysema,  though  there  is  little  or  no  anterior  expansion. 

HydrotJiorax. — In  hydrothorax  we  have  a  condition,  on  both 
sides,  similar  to  that  found  in  pleurisy  with  effusion  upon  one 
side.  This  gives  rise  to  loss  of  motion  and  to  more  or  less 
bulging  of  the  infra-axillary  regions. 

Pericarditis. — In  this  affection,  if  the  amount  of  effusion  is 
sufficient,  there  is  considerable  bulging  of  the  prascordial 
region,  especially  when  the  disease  occurs  in  children ;  but  in 
adults  and  older  patients,  on  account  of  the  firmness  of  the  car- 
tilages, this  is  not  so  likely  to  occur.  There  is  also  diminution 
of  the  respiratory  movements  on  the  left  side,  due  to  pressure 
from  the  distended  pericardium. 

Hypertrophy  of  the  Heart. — This  disease  will  also  occasion 
local  bulging,  most  marked  in  young  patients.  The  impulse 
of  the  apex,  if  visible,  will  be  seen  to  the  left,  and  below  its 
normal  position.  Its  area  will  also  be  increased. 

Tumors  within  the  thoracic  cavity  will  give  rise  to  bulging 
as  soon  as  they  have  attained  sufficient  size  to  press  up6n  the 
parietes. 

If  the  tumor  happen  to  be  aneurismal,  or  if  it  be  solid  and 
rests  upon  a  large  artery,  it  will  be  very  likely  to  pulsate  syn- 
chronously with  the  contraction  of  the  heart.  An  enlarged 
liver  or  an  enlarged  spleen  may  occasion  local  bulging. 

In  cases  of  pneumothorax  and  pleurisy  with  great  effusion, 
we  obtain  valuable  information  by  examining  the  impulse 


,g  PULMONARY    DISEASES. 

caused  by  the  apex  of  the  heart,  which  will  be  seen  crowded 
from  its  normal  position  toward  the  unaffected  'side. 

Membranous  croup. — In  membranous  croup  and  in  several 
other  affections  of  the  larynx  or  of  the  trachea,  such,  for 
example,  as  oedema  glottidis,  foreign  bodies  in  the  larynx  or 
in  the  trachea,  or  morbid  growths,  the  amount  of  air  entering 
the  lung  at  each  inspiration  is  considerably  less  than  normal. 
This  has  the  effect  of  prolonging  inspiration  and  of  rendering  it 
laborious,  though  expiration  is  not  notably  affected.  In  these 
affections  the  respiration  is  not  quickened  as  in  most  pulmo- 
nary diseases,  and  it  may  be  even  slower  than  usual.  The  diffi- 
culty in  respiration,  in  these  cases,  differs  from  that  in  emphy- 
sema in  that  here  there  is  obstruction  to  inspiration,  and  in  the 
latter  the  principal  obstacle  is  in  the  way  of  expiration. 

In  all  of  these  affections  of  the  larynx  and  of  the  trachea, 
when  the  obstruction  is  considerable,  we  will  observe  sinking 
of  the  soft  parts  of  the  chest  above  the  clavicle  and  in  the 
intercostal  spaces,  especially  at  the  lower  part  of  the  chest, 
during  the  inspiratory  act.  This  is  due  to  atmospheric  press- 
ure from  without,  as  the  chest-walls  expand  more  rapidly 
than  air  can  enter  through  the  obstructed  passage  to  fill  the 
lungs. 

Bronchitis. — In  chronic  bronchitis  the  signs  obtained  by 
inspection  are  of  little  value,  though  we  may  occasionally 
observe  prolonged  expiration,  and  in  some  instances,  there  is 
irregular  expansion  of  the  chest-walls,  in  different  parts,  due 
to  plugging  of  the  bronchial  tubes  by  their  secretions.  Most 
cases  of  chronic  bronchitis  are  associated  with  emphysema. 

PALPATION. 

This  method  consists  of  physical  exploration  by  the  sense  of 
touch,  either  by  the  tips  of  the  fingers  or  with  the  palms  of  the 
hands. 

In  practicing  palpation  upon  the  chest,  the  palmar  surface  of 
the  hands  should  be  used,  and  in  many  instances  you  will  find 
it  desirable  to  cross  the  hands  so  that,  as  you  sit  in  front  of  the 
patient,  your  right  hand  rests  upon  his  right  side,  and  your  left 
upon  his  left  side. 

If  the  signs  to  be  obtained  are  only  slight,  you  will  thus  ap- 
preciate them  more  clearly. 


PALPATION.  Xp 

By  the  sense  of  touch,  we  are  enabled  to  appreciate  very 
slight  alterations  in  the  movements  of  the  thoracic  walls,  and 
sometimes  to  detect  intra-thoracic  tumors  which  cause  no  bul- 
ging of  the  surface.  By  this  method  we  determine  the  nature 
of  tumors,  whether  they  are  hard  or  soft,  solid  or  fluid,  and 
whether  or  not  they  pulsate.  By  it,  we  differentiate  between 
the  pain  found  in  three  points  along  the  course  of  the  superfi- 
cial nerves  in  intercostal  neuralgia,  and  the  pain  found  in  the 
superficial  muscles  in  pleurodynia,  or  deep-seated  in  pleurisy. 

The  information  regarding  size,  form,  and  movements,  which 
is  obtainable  by  this  method,  is  essentially  the  same  as 
that  furnished  by  inspection.  If  your  hand  is  placed  gently 
upon  the  chest  of  a  healthy  person  while  he  is  speaking,  you 
will  notice  a  peculiar  trembling  of  the  chest-wall  which  is 
known  as  the  normal  vocal  fremitus.  It  is  produced  by  the 
transmission  to  the  chest-wall  of  the  vibrations  of  air  in  the 
bronchi,  caused  by  the  act  of  speaking.  Modifications  of  the 
vocal  fremitus  are  among  the  most  important  signs  which  are 
obtained  by  this  method. 

The  normal  vocal  fremitus  varies  in  different  individuals.. 
It  is  not  usually  marked  in  women  and  children.  In  males  it 
will  be  found  more  or  less  defined  in  proportion  to  the  pitch  or 
force  of  the  voice.  Voices  of  low  pitch  cause  a  more  distinct 
fremitus  than  those  which  are  higher.  The  distinctness  of  this 
sign  will  also  depend  upon  the  thickness  of  the  chest-walls, 
upon  the  diameter  of  the  bronchi  conveying  the  vibrations  to 
the  chest-wall,  upon  the  proximity  of  the  bronchi  to  the  parie- 
tes,  and  also  upon  the  distance  of  the  point  examined  from 
the  larynx.  It  is,  therefore,  more  marked  upon  the  right  than 
upon  the  left  side,  and  in  the  infra-clavicular  region  than  in  the 
lower  part  of  the  chest. 

In  adult  females,  this  sign  may  be  obtained  over  the  upper 
portion  of  the  chest,  but  it  is  seldom  found  over  the  lower  part. 
In  males  it  is  usually  perceptible  over  the  whole  chest. 

The  normal  vocal  fremitus  is  altered  by  disease  in  its  force, 
which  may  be  increased  or  diminished  ;  or  the  fremitus  may 
be  absent.  As  a  rule,  it  is  increased  by  all  those  diseases 
which  cause  consolidation  of  lung  tissue.  The  most  important 
of  these  are  phthisis,  pneumonia,  cedema,  and  apoplexy  of  the  lungs. 
The  fremitus  is  generally  increased  by  dilatation  of  the  bronchial 


2O  PULMONARY   DISEASES. 

tubes,  in  which  there  is  more  or  less  induration  of  the  paren- 
chyma of  the  lungs. 

Exceptional. — There  is  an  exception  to  this  rule  in  pneumonia,  when  the  bronchial 
tubes  are  completely  filled  by  the  inflammatory  deposit.  In  such  an  instance  the  vocal 
fremitus  would  not  be  felt. 

Owing  to  the  great  variation  of  this  sign  in  different  indi- 
viduals, and  to  its  mutations  in  disease  without  clearly-defined 
causes,  it  is  not  of  very  much  value  when  taken  alone. 

The  vocal  fremitus  is  diminished  or  suppressed  by  any 
disease  which  separates  the  lung  from  the  chest-wall,  whether 
it  be  by  the  intervention  of  air,  of  gas,  or  of  fluid  between 
the  pleural  surfaces.  In  pneumothonax,  in  hydrothorax,  and  in 
pleurisy  with  effusion,  absence  of  vocal  fremitus  over  the  air  or 
the  fluid  is  a  sign  of  great  value. 

Exceptional. — Its  presence  is  not  always  a  certain  sign  that  fluid  does  not  exist,  as 
shown  by  a  few  rare  cases.  If  these  diseases  are  only  slight,  so  that  there  is  but  a 
small  collection  in  the  pleural  sac,  the  vocal  fremitus  is  simply  diminished. 

In  the  early  stage  of  pleurisy,  an  exudation  of  lymph  takes 
place  upon  the  surface,  which  often  becomes  formed  into  new 
tissue,  and  remains  after  recovery.  Although  this  separates 
the  lung  from  the  chest-wall,  it  does  not  materially  alter  the 
vocal  fremitus. 

Emphysema. — In  emphysema  the  vocal  fremitus  is  diminished. 

Aneurismal  or  other  intra-thoracic  tumors  cause  a  diminu- 
tion or  an  absence  of  the  vocal  fremitus  directly  over  them, 
providing  no  lung  tissue  intervenes  between  .the  tumor  and 
the  chest-wall. 

The  evidence  derived  from  a  study  of  the  vocal  fremitus  is 
principally  of  value  in  differentiating  between  consolidation  of 
lung  tissue  and  fluid  in  the  lower  part  of  the  chest.  When  the 
lung  tissue  is  consolidated,  the  fremitus  is  increased.  When 
there  is  a  collection  of  fluid,  it  is  absent.  The  exceptions  to  this 
rule  are  so  few  that  they  hardly  need  a  thought. 

Friction  and  Ronchial  Fremitus. — Vibrations  caused  by  rub- 
bing together  of  the  roughened  surfaces  of  the  pericardium  or 
pleura,  or  by  bubbling  of  air  through  fluid  in  the  air-passages, 
may  often  be  detected  by  palpation.  Those  produced  within 
the  pleural  or  the  pericardial  sacs  are  known  as  friction  fremitus, 
and  are  indicative  of  inflammation  of  these  membranes,  with 


MENSURATION.  21 

exudation,  which  causes  roughening  of  the  surface.  In  acute 
or  in  chronic  bronchitis,  especially  in  children,  when  secretion 
is  abundant,  the  chest-walls  are  thrown  into  vibration  by  air 
bubbling  through  fluid  within  the  bronchi.  These  vibrations 
are  termed  the  ronchial  or  broncJiial  fremitus.  They  communi- 
cate to  the  hand  a  distinct  bubbling  sensation,  which  cannot  be 
mistaken. 

Fluctuation  of  fluid  within  the  pleural  cavity  may  often  be 
felt  in  the  intercostal  spaces  by  the  fingers  of  one  hand,  while 
tapping  at  a  little  distance  with  the  fingers  of  the  other  hand. 

MENSURATION. 

Mensuration,  or  measurement  of  the  chest,  is  a  method 
not  ordinarily  used,  excepting  when  we  wish  to  make  a  record 
of  the  case,  as  the  signs  which  it  furnishes  can  usually  be  ob- 
tained with  sufficient  accuracy  and  much  more  quickly  by  the 
two  preceding  methods.  A  great  variety  of  instruments  have 
been  devised  for  determining  the  size  and  the  capacity  of  the 
chest,  as  well  as  its  degrees  of  curvature  or  of  flatness.  The 
only  measurement  which  is  of  any  special  clinical  value  is  that 
of  the  circumference,  in  inspiration  and  in  expiration,  which 
may  be  readily  taken  by  means  of  a  simple  tape.  A  very  good 
device  for  measuring  the  size  of  the  chest  consists  of  two 
tapes  joined  at  their  extremities  and  so  padded  near  the  line 
of  junction  as  to  form  a  sort  of  saddle,  which  rests  upon  the 
spinous  processes  and  prevents  slipping. 

In  using  this  instrument,  adjust  the  pads  to*  the  spine,  and 
carry  the  tapes  about  the  chest  on  both  sides,  to  the  median 
line  in  front.  The  exact  amount  of  motion  of  the  two  sides 
may  be  easily  ascertained  in  this  manner. 

In  measuring  with  a  single  tape,  the  best  method  is  to  place 
your  thumb  nail  at  a  certain  point  on  the  tape,  with  the  first 
finger  about  one  fourth  of  an  inch  nearer  its  end.  Then  press 
the  tape  with  the  thumb  nail  against  the  middle  of  a  spinous 
process  and  .press  the  forefinger  down  beside  it.  This  will 
enable  you  to  hold  the  tape  firmly  in  position,  and  by  prevent- 
ing the  skin  from  sliding  in  respiration,  will  give  you  a  fixed 
point  from  which  to  measure. 

It  is  always  desirable  to  mark  the  median  line  in  front  be- 
fore commencing  this  measurement.  The  circumference  of  the 


22 


PULMONARY   DISEASES. 


chest  may  be  taken  above  or  below  the  nipples,  but  the  best  place 
is  on  a  level  with  the  sixth  costo-sternal  articulation.  In  record- 
ing cases,  you  should  always  note  the  level  of  the  measurement. 
The  measurement  should  be  taken  both  during  full  inspira- 
tion and  during  forced  expiration,  and  the  two  should  be 
compared  to  determine  the  full  amount  of  expansion.  The  two 
sides  must  be  compared  to  ascertain  whether  either  is  distended 
or  more  or  less  deficient  in  movement.  Doctors  Quain  and 
Carroll  invented  very  satisfactory  instruments  for  taking  these 

measurements,  known  as  stetho- 
meters.  Dr.  Quain's  instrument 
(Fig.  4)  consists  of  a  cylindrical 
box  with  a  dial  and  an  index, 
which  is  moved  by  a  rack  to 
which  is  attached  a  cord  long 
enough  to  compass  the  chest. 
Each  rotation  of  the  index  about 

FIG.  4. — Ouain's  Stethometer.  «.il       j«"  i    •    j;  •       u 

the   dial  indicates  one  inch   of 

movement.  In  using  it,  the  box  is  placed  upon  the  centre  of 
the  chest  in  front,  and  the  string  is  carried  horizontally  around 
the  chest;  then,  as  the  patient  inspires  and  expires,  the  index 
will  revolve  about  the  dial,  registering  minutely  and  accurately 
the  expansion  of  the  chest-walls.  Dr.  Carroll's  stethometer  is 
simple  and  exact  (Fig.  5).  Ordinarily,  the  physician  may  as 
well  use  the  simple  tape. 


FIG.  5. — Carroll's  Stethometer. 

The  measurements  of  the  healthy  chest,  of  course,  vary  in  dif- 
ferent individuals.  The  average  is  thirty-two  and  one  half  inches. 
Generally,  the  right  side  exceeds  the  left  by  half  an  inch,  but 
in  left-handed  persons  the  left  side  is  usually  the  larger. 

In  disease,  the  affected  side  may  be  distended  or  contracted, 
and  its  movements  may  be  diminished  or  increased.  These  con- 
ditions are  usually  noticeable  on  inspection  and  by  palpation. 
but  they  may  be  more  accurately  determined  by  mensuration. 


MENSURATION.  23 

It  is  not  uncommon  to  find,  upon  mensuration,  that  a  side  which 
had  the  appearance  of  distention  is  smaller  than  its  fellow  ;  and 
frequently  expansion,  which  has  seemed  comparatively  free, 
by  the  tape  will  be  found  not  to  exceed  one  eighth  of  an  inch. 

The  diseases  causing  expansion  or  contraction,  and  loss  of 
movements  of  the  chest-walls,  were  mentioned  in  speaking  of 
inspection. 

The  transverse  diameter  of  the  chest  may  be  obtained  by  means 
of  a  pair  of  calipers,  or  by  Prof.  Flint's  cyrtometer  (Fig.  6). 


FIG.  6. — Cyrtometer. 

Dr.  Gee's  cyrtometer,  which  consists  of  two  pieces  of  com- 
position gas  pipe  joined  together  by  means  of  a  piece  of  rubber 
tubing,  is  the  cheapest,  and  perhaps  the  best  instrument 
for  ascertaining  the  transverse  outline  of  the  chest.  In  using 
it,  the  joint  is  placed  upon  the  spine,  and  the  pieces  of  pipe 
are  accurately  moulded  round  the  chest.  The  instrument 
is  then  removed  and  laid  on  paper,  when  an  exact  tracing  can 
be  made.  In  a  well-formed  chest,  the  antero-posterior  diame- 
ter between  the  spine  and  the  sternum,  will  be  to  the  transverse 
diameter,  in  males,  as  three  to  four,  in  females,  as  four  to  five 
(Fig.  3,  page  1 1).  Dr.  Allison  invented  an  instrument,  known 
as  a  stethogoniometer,  for  measuring  the  curves  or  the  flatness 
of  the  surface  of  the  chest  (Fig.  7).  It  has  been  claimed  by 
some  physicians,  that  the  infra-clavicular  space  should  always 
be  convex  in  healthy  persons.  With  this  instrument  the  curv- 
atures could  be  accurately  ascertained,  but  unfortunately,  the 
information  is  of  very  little  value,  because,  in  healthy  individ- 
uals, this  region  is  often  flat  or  even  concave. 


24  PULMONARY   DISEASES. 

Spirometers  are  used  for   measuring  the   capacity  of   the 
chest.      Dr.    Hutchinson   was,   1    think,   the   inventor  of   the 


FIG.  7. — Allison's  Stethogoniometer. 

spirometer,  but   many   modifications  have   been   made  since. 

Recently  instruments  have  been  made  for  the  same  purpose 

about  the  size  of  a  watch,  so 
that  they  may  be  carried  in  the 
pocket. 

In  one  of  these,  which  is  manu- 
factured in  this  city,  as  the 
patient  inspires,  or  blows  into 
the  tube,  the  index  revolves  on 
the  dial,  registering  the  exact 
number  of  cubic  inches  of  .air 
which  have  been  inhaled  or 
expired.  Another  instrument, 
devised  by  the  same  party,  con- 
sists of  a  rubber  sac  and  a  gradu- 
ated tape  for  measuring  its  cir- 
cumference when  inflated.  In 
using  this,  the  patient  inflates 
the  sac  as  fully  as  possible  with 
one  expiration,  and  then  meas- 
ures its  circumference  with  the 
tape,  which  is  so  graduated  as  to 
indicate  the  number  of  cubic 
inches  of  air  which  the  sac  con- 
tains. The  instruments  of  this 
kind  which  I  have  seen,  easily 
get  out  of  order. 


FIG.  8. — Hutchinson's  Spirometer. 


Dr.  Hutchinson  found  that  people  five  feet  in  height,  usually 
possess  a  vital  capacity  of  one  hundred  and  seventy-four  cubic 


MENSURATION. 


inches,  and  for  every  inch  above  five  feet,  eight  inches  should  be 
added  to  the  healthy  standard.  There  are  many  obstacles  to 
the  use  of  this  method  which  render  it  practically  useless.  For 


FIG.  9. — Hammond's  Hcemadynamometer. 

instance,  it  takes  most  persons  a  longtime  to  learn  how  to  blow 
into  one  of  these  instruments.  A  patient  may  at  one  time  ex- 
pire only  one  hundred  and  fifty  cubic  inches,  and  at  another 
time,  without  any  change  in  his  health,  the  instrument  might 


26  PULMONARY   DISEASES. 

register  two  hundred  cubic  inches.  Again  females  and  males, 
the  young  and  the  old,  all  have  different  vital  capacities,  and  it 
has  never  yet  been  possible  to  arrive  at  an  accurate  healthy 
standard. 

Dr.  Hammond  devised  an  instrument  known  as  the  Hsema- 
dynamometer,  which  he  used  for  measuring  the  forcf  of  inspi- 
ration and  of  expiration.  From  his  observations,  he  found 
that  individuals  of  five  feet  eight  inches  in  height  possess  the 
maximum  respiratory  power.  His  instrument  (Fig.  9)  consists 
of  a  bent  glass  tube  fastened  to  a  graduated  scale,  and  joined  at 
each  end  by  a  rubber  tube,  through  which  the  patient  is  to 
breathe.  The  instrument  is  partially  filled  with  mercury 
which  rises  on  one  side  or  the  other  as  the  patient  attempts  to 
inspire  or  to  expire  through  the  mouth-piece,  and  falls  after  he 
ceases. 

Dr.  Hammond  found  that  the  expiratory  power  was  consider- 
ably more  than  the  inspiratory  ;  the  average  man  being  able  to 
raise  the  column  of  mercury  three  inches  by  expiration,  and 
only  two  inches  by  inspiration.  This  is  a  fact  which  you 
should  not  forget,  because  it  at  once  explains  some  of  the 
phenomena  of  disease.  For  instance,  Laennec's  theory  as  to  the 
cause  of  pulmonary  emphysema  was  based  upon  the  supposi- 
tion that  the  inspiratory  power  was  greater  than  the  expira- 
tory. Those  who  have  adopted  this  theory  could  not  have 
held  it  for  a  single  instant  had  they  known  the  facts  so  clearly 
demonstrated  by  this  instrument. 
i 

SUCCUSSION. 

The  fourth  method  of  physical  exploration  to  which  I  wish 
to  direct  your  attention  was  known  to  Hippocrates.  It  is 
termed  succussion.  This  consists  of  suddenly  shaking  the  pa- 
tient's body  while  the  ear  is  placed  against  his  chest. 

When  air  and  fluid  occupy  the  pleural  sac,  this  proceeding 
will  cause  a  splashing  sound,  similar  to  that  which  may  be 
heard  by  shaking  a  bottle  partially  filled  with  fluid.  The  sign 
is  of  value  in  the  single  disease,  pneumo-hydrothorax  (Fig. 
22,  page  98).  The  succussion  sound  will  vary  more  or  less 
in  quality  with  the  density  of  the  fluid.  Thick  pus  will  not 
yield  the  same  sound  as  thin  serum,  but  the  quality  of  these 


SUCCUSSION.  27 

sounds  is  not  usually  sufficiently  distinctive  to  aid  us  materially 
in  our  diagnosis. 

Metallic  tinkling,  due  to  dropping  of  fluid  from  the  upper 
part  of  the  cavity  into  the  effusion  below,  can  usually  be  heard 
when  the  succussion  signs  are  present  (Fig.  22,  page  98). 


LECTURE    III. 

PERCUSSION. 

Percussion  is  the  art  of  eliciting  sound  by  striking-  with  the 
fingers,  or  with  instruments  constructed  for  the  purpose. 

As  a  means  of  diagnosis,  it  is  generally  supposed  to  have 
originated  during  the  last  century  with  Avenbrugger,  a  physi- 
cian of  Vienna,  but  the  works  of  Hippocrates  indicate  that  he 
was  familiar  with  it,  to  a  limited  extent. 

The  method  recommended  by  Hippocrates,  and  which  was 
practiced  by  Avenbrugger,  was  that  which  is  now  known  as  im- 
mediate percussion,  in  which  the  blow  is  struck  directly  upon 
the  chest-wall. 

This  form  of  percussion  has  been  nearly  supplanted  by  one 
which  originated  about  fifty  years  ago,  with  M.  Piorry,  termed 
mediate  percussion,  in  which  the  blow  is  received  on  some  in- 


Fio.   10  — Flint's  Hammer  and  Pleximeter. 

tervening  substance.  Before  mediate  percussion  was  employed, 
it  was  quite  essential  to  intensify  the  sounds  in  some  way  ;  this 
was  accomplished  by  placing  the  patient  with  his  back  against 
a  hollow  wall.  In  some  females  the  signs  elicited  by  immediate 
percussion  are  quite  distinct  over  the  upper  part  of  the  chest, 
but  usually  this  method  is  very  unsatisfactory.  In  the  method 
now  most  commonly  practiced,  known  as  mediate  percussion, 
certain  instruments  are  used,  consisting  of  a  small  hammer  or 
plexor,  and  an  instrument  known  as  a  pleximeter  or  plessimeter. 
The  hammers  in  common  use  consist  of  a  cylindrical  rubber 


PERCUSSION.  2£* 

head  attached  to  a  light  handle  about  eight  inches  in  length. 
Metallic  hammers  faced  with  rubber  are  sometimes  employed, 
but  they  are  objectionable  on  account  of  their  weight,  which 
renders  the  blow  so  forcible  that  it  is  likely  to  cause  pain. 
Pleximeters  are  made  of  various  materials,  as  rubber,  bone, 
wood,  ivory,  and  leather.  Some  of  them  are  graduated  on  the 
surface,  in  order  that  they  may  be  used  in  mensuration. 

The  one  which  I  think  the  best  consists  of  a  narrow  oval 
disk  of  hard-rubber,  with  large  ears  at  each  extremity.  The 
instrument  should  be  narrow  in  order  that  it  may  be  placed 
between  the  ribs,  and  it  should  have  a  large  projecting  piece 
at  each  end,  so  that  it  may  be  firmly  grasped.  I  have  used  con- 
siderably as  a  pleximeter  a  small  cylinder  of  soft  rubber  about 
two  inches  long  and  half  an  inch  in  diameter.  It  has  the  ad- 
vantage over  most  pleximeters  of  being  easily  adapted  to  the 
intercostal  spaces,  and  of  emitting  no  sounds  of  its  own  when 
struck.  For  ordinary  percussion  you  will  do  better  to  throw 
aside  these  instruments  entirely,  using  the  middle  or  index 
finger  of  the  left  hand  in  place  of  the  pleximeter,  and  two  or 
three  fingers  of  the  right  hand,  with  their  tips  brought  into 
line,  as  a  hammer.  The  fingers  of  the  right  hand  should  be 
brought  as  nearly  to  a  right  angle  at  the  second  joint  as  can  be, 
so  that  the  terminal  phalanges  may  strike  vertically  upon  the 
finger  of  the  left  hand. 

There  is  a  certain  sense  of  resistance  noticeable  when  per- 
cussion is  performed  with  the  fingers,  which  is  entirely  lost  if 
we  employ  instruments.  Often  this  sense  of  resistance  would 
enable  us  to  detect  changes  in  the  intra-thoracic  organs,  even 
if  our  ears  were  completely  stopped.  This  is  so  valuable  in 
intricate  cases  that,  when  I  have  any  difficulty  in  making  an 
accurate  diagnosis,  I  always  employ  the  fingers  instead  of 
instruments. 

The  sounds  obtained  by  percussion  are  generally  described  . 
as  clear,  dull,  and  tympanitic,  but  these  terms  are  not  sufficiently 
precise  to  aid  you  much  in  studying  the  method.  I  prefer  a 
classification  of  these  sounds,  based  upon  their  acoustic  prop- 
erties. The  elements  of  sound  which  concern  us  in  percus- 
sion are  intensity,  pitch,  quality,  and  duration. 

INTENSITY. — The  intensity  of  a  sound  is  the  element  which 
determines  the  distance  at  which  the  sound  may  be  heard.. 


»  30  PULMONARY   DISEASES. 

Other  things  being  equal,  the  intensity  of  a  sound  in  pulmonary 
percussion  varies  with  the  force  of  the  blow,  the  volume  of 
air  in  the  lung,  and  with  the  thickness  and  the  elasticity  of 
the  chest-walls.  It  is  diminished  by  thick  layers  of  fat  or  mus- 
cle, by  rigidity  of  the  costal  cartilages,  and  by  contraction 
or  consolidation  of  the  lung,  and  it  is  increased  by  the  oppo- 
site conditions. 

PITCH. — The  pitch  of  a  percussion  sound  is  subject  to  the  same 
variations  as  the  pitch  of  musical  notes  ;  that  is,  it  may  be  high 
or  low.  Any  one  familiar  with  music  will  understand  this,  but 
it  is  a  common  mistake  to  confound  pitch  with  intensity.  Many 
students  suppose  that  the  higher  the  pitch  of  a  sound,  the 
greater  will  be  its  intensity.  The  reverse  of  this  is  usually 
true  in  pulmonary  percussion,  intense  sounds  being  low  pitched, 
and  high-pitched  sounds  possessing  feeble  intensity. 

Any  of  you  can  recognize  this  difference  between  pitch  and 
intensity,  by  striking  two  notes  at  opposite  ends  of  the  key- 
board of  a  piano.  By  striking  a  high  note  forcibly  you  will 
obtain  a  sound  loud  enough  to  be  heard  some  distance,  then 
by  gently  tapping  a  key  at  the  other  end,  you  will  obtain  a 
sound  which  can  be  heard  at  exactly  the  same  distance,  but 
which  is  of  a  much  lower  pitch. 

The  pitch  of  the  percussion  note  over  a  healthy  lung  is  al- 
ways low,  but  it  will  vary  in  different  portions  of  the  chest, 
owing  to  the  difference  in  the  volume  of  air  and  to  the  position 
of  other  intra-thoracic  organs. 

QUALITY. — The  quality  of  sound  is  that  element  by  which  we 
distinguish  between  the  tones  of  musical  instruments,  and  by 
which  we  distinguish  the  voices  of  different  individuals,  which 
may  have  the  same  intensity  and  the  same  pitch. 

In  pulmonary  percussion,  we  obtain  a  peculiar  quality  which 
is  termed  vesicular.  Language  cannot  describe  it,  but  it  may 
always  be  obtained  by  percussing  the  healthy  chest.  This 
sound  is  soft  and  low  in  pitch,  and  usually  seems  as  though  it 
came  from  a  point  a  couple  of  inches  beneath  the  surface.  You 
can  learn  it  only  by  studying  the  healthy  chest. 

DURATION. — The  duration  of  the  healthy  percussion  note  is 
dependent  upon  the  same  causes  as  its  pitch.  If  its  pitch  is 
high,  the  duration  is  short ;  if  the  pitch  is  low,  the  duration  is 
prolonged.  Indeed  we  find  a  definite  relation  existing  between 


PERCUSSION.  3I 

all  of  these  different  elements;  that  is,  sounds  which  are  intense 
are  apt  to  he  low  pitched  ;  sounds  which  are  feeble  are  gener- 
ally short  and  high  pitched,  and  instead  of  the  vesicular  qual- 
ity, they  possess  a  solid  character. 

Percussion  seems  very  simple  as  you  see  it  practiced  by  an 
adept,  but  you  will  find  that  accuracy  is  not  acquired  without 
much  practice. 

There  are  certain  rules  which  it  is  essential  to  follow  for  ac- 
curate percussion.  In  order  that  you  may  the  more  readily 
become  skilful,  I  wish  to  fix  them  in  your  minds. 

First.  Have  regard  to  the  covering  of  the  patient's  chest. 
The  surface  should  be  bare,  but  if  for  any  reason  this  cannot 
be  secured,  have  the  covering  soft,  thin,  and  smooth.  It  is 
absolutely  useless  to  percuss  the  chest  of  a  patient  who  has  on 
one  or  two  shirts,  and  perhaps  a  chest  protector  and  corsets. 

Second.  The  patient  should  be  in  a  comfortable  position, 
whether  sitting,  standing,  or  lying  upon  the  back,  and  the  two 
sides  must  be  in  corresponding  positions. 

Third.  You  must  not  allow  the  patient  to  twist  the  body  or 
to  move  the  arms,  while  percussion  is  being  made,  because 
such  motions  will  change  the  relations  of  the  muscles,  and  thus 
alter  the  percussion  note.  Your  own  position  should  be  easy 
and  unrestrained,  or  you  will  not  recognize  slight  differences 
in  sound. 

Fourth.  It  is  quite  important  that  the  physician  should  be 
squarely  in  front  of  the  patient.  If  he  stand  partially  to  one 
side,  the  signs  obtained  on  that  side,  even  though  they  may  be 
the  same  as  those  on  the  other  side,  will  reach  the  ear  with  a 
different  tone. 

Fifth.  In  percussing  any  particular  region  of  the  chest,  you 
should  aim  to  have  the  chest-walls  as  thin  and  as  tense  as  pos- 
sible. To  secure  this  when  examining  the  anterior  portions  of 
the  chest,  the  arms  should  hang  at  the  side  and  the  shoulders 
should  be  thrown  backward.  In  examining  the  lateral  regions, 
it  is  a  good  plan  to  have  the  hands  rested  upon  the  head.  If 
the  arms  are  held  up,  the  muscles  stand  out  so  prominently 
that  they  interfere  with  obtaining  the  pulmonary  resonance. 
In  percussing  the  posterior  regions,  the  trunk  should  be  bent 
forward  and  the  arms  crossed  in  front. 

The  patient  may  be  sitting,  standing,  or  recumbent.     The 


32  PULMONARY   DISEASES. 

first  two  positions  are  preferable,  but  I  would  advise  you  not 
to  have  very  sick  patients  rise  for  the  examination  ;  it  will  be 
better  to  make  a  less  critical  examination  than  to  endanger  your 
patient.  I  have  seen  a  vigorous  man,  suffering  from  pneumonia, 
fall  dead,  simply  from  getting  quickly  out  of  bed.  Persons 
suffering  from  diseases  which  cause  feebleness  of  heart,  should 
not  be  asked  to  sit  or  to  stand.  I  recently  saw  the  necessity 
of  caution  in  these  cases  illustrated  in  a  little  patient  conva- 
lescing from  diphtheria.  The  child  had  no  symptoms  of  paraly- 
sis, but  when  she  got  out  of  bed  and  stood  for  a  minute  or  two, 
the  heart  stopped,  simply  because  it  was  overtaxed. 

Sixth.  In  percussing  the  chest,  we  must  compare  correspond- 
ing portions  of  the  two  sides.  If  changes  from  the  normal 
condition  are  slight,  they  can  be  detected  in  no  other  way. 
The  percussion  sound  varies  slightly  at  different  periods  of  the 
act  of  respiration.  Therefore,  whenever  the  changes  are  so 
slight  as  to  require  great  care  for  their  discrimination,  the  sides 
should  be  compared  during  the  same  stage  of  the  respiratory 
act.  Ordinarily  it  is  sufficient  to  repeat  a  series  of  strokes 
first  on  one  side,  then  on  the  other,  or  to  percuss  both  sides  re- 
peatedly in  quick  succession.  The  best  period  at  which  to 
make  the  comparison  is  at  the  close  of  a  forced  expiration. 

Exceptional  — In  health  the  two  sides  are  not  always  equally  affected  as  regards  the 
disparity  between  the  note  elicited  in  full  inspiration  and  that  elicited  in  forced  expira- 
tion. 

Seventh.  In  applying  the  finger  or  the  pleximeter,  be  careful 
that  it  presses  evenly  upon  the  surface  and  displaces  all  the  air 
from  beneath  it.  Otherwise,  in  percussing,  the  resonance  of  the 
pleximeter  is  obtained  instead  of  that  from  the  chest,  and  at  the 
same  time  the  air  is  suddenly  forced  out,  causing  a  sound  very 
similar  to  that  known  as  "  cracked-pot  "  resonance. 

Eighth.  The  force  of  the  stroke  should  be  moderate  ;  and 
alike  on  both  sides.  It  should  never  be  great  enough  to  cause 
the  patient  pain.  In  percussing  the  superficial  portions  of  the 
lung,  the  stroke  should  be  very  gentle,  but  it  must  be  more 
forcible  to  obtain  the  resonance  from  deeper  parts.  Beginners 
commonly  strike  much  too  hard. 

The  stroke  should  be  from  the  wrist  alone,  whether  made 
with  the  hammer  or  with  the  finger.  When  striking  from  the 
elbo\y,  we  cannot  control  the  force  of  the  blow.  Some  diag- 


PERCUSSION.  22 

nosticians  are  accustomed  to  strike  slowly,  with  a  single  blow, 
first  upon  one  side,  then  upon  the  other;  but  I  think  we  get  bet- 
ter results  by  making  three  or  four  taps  in  rapid  succession. 

The  direction  of  the  stroke  is  a  matter  of  considerable  im- 
portance. It  should  always  be  perpendicular  to  the  surface  of 
the  chest.  If  we  percuss  obliquely,  instead  of  obtaining  the 
resonance  from  the  lung  immediately  beneath  the  pleximeter, 
we  get  that  from  a  rib  or  from  more  distant  tissue. 

In  percussing  near  the  sternum,  in  the  upper  portion  of  the 
chest,  we  obtain  resonance  from  the  trachea  instead  of  from 
the  lung  tissue,  unless  care  be  taken  to  direct  the  blow  toward 
the  central  portion  of  the  apex. 

Ninth.  The  stroke  should  be  a  simple  tap,  the  finger  or  ham- 
mer being  allowed  to  rebound  instantly,  instead  of  resting  on 
the  pleximeter  a  moment  after  the  blow  has  been  given.  Al- 
lowing the  fingers  or  the  hammer  to  rest  a  moment  on  the  plex- 
imeter, has  an  effect  on  the  pulmonary  resonance  similar  to 
that  produced  by  touching  one  of  the  prongs  of  a  vibrating 
tuning  fork.  In  percussing  with  the  fingers,  be  careful  to 
strike  with  their  tips,  instead  of  with  the  pulps. 

As  the  signs  in  a  healthy  chest  vary  in  its  different  regions, 
you  must  take  special  pains  to  familiarize  yourselves  with  all 
the  healthy  sounds.  There  are  no  two  healthy  people  whose 
chests  are  exactly  alike,  therefore  you  can  take  no  one  person 
as  a  standard  for  comparison,  but  after  percussing  many  healthy 
chests,  you  may  form  for  yourselves  an  ideal  standard  from 
which  no  great  variation  can  occur  without  indicating  disease. 

In  health  the  most  perfect  vesicular  resonance  is  obtained  in 
the  left  infra-clavicular  region,  and  this,  being  the  sound  ob- 
tained over  the  parenchyma  of  the  lung  or  air  vesicles,  is  taken 
as  the  standard  for  comparison  in  pulmonary  percussion.  It  is 
named  normal  vesicular  resonance. 

In  the  right  infra-clavicular  region  the  percussion  note  is 
nearly  the  same,  but  it  is  slightly  harder  or  more  tubular  in 
quality  owing,  probably,  to  the  greater  size  of  the  bronchial 
tubes. 

In  the  middle  of  the  supra-clavicular  region,  the  resonance 

is  soft  or  vesicular  in  quality,  but  as   we  approach  the  inner 

part  of  this  region,  it  becomes  harder  in  quality  or  tubular,  and 

higher  in  pitch.     Dr.  Flint  calls  this  an  approach  to  tympanitic 

3 


34 


PULMONARY   DISEASES. 


resonance.  Externally  in  this  region  the  vesicular  quality  is 
diminished.  In  percussing  over  the  central  portion  of  the 
clavicular  region,  the  sound  is  fairly  vesicular,  but  it  becomes 
less  and  less  so  as  we  approach  either  end  of  the  clavicle. 

In  the  mammary  regions  the  sounds  are  altered  on  one  side 
by  the  presence  of  the  heart,  and  on  the  other  side  by  the  pres- 
ence of  the  liver  (Fig.  i,  page  3).  In  the  upper  part  of  the 
right  mammary  region,  we  obtain  vesicular  resonance  which 
extends  down  to  the  line  of  hepatic  dulness  in  the  fourth  inter- 
space. Below  this,  on  forcible  percussion,  dulness  is  apprecia- 
ble which  gradually  becomes  more  and  more  distinct  until  we 
reach  the  lower  border  of  the  lung  at  the  sixth  rib.  This  point 
is  known  as  the  line  of  hepatic  flatness ;  below  which  we  lose 
all  pulmonary  resonance. 

The  lines  of  hepatic  dulness  and  of  hepatic  flatness,  the  first 
at  the  uppermost  part  of  the  liver,  and  the  second  at  the  lower 
margin  of  the  lung,  are  ordinarily  about  two  inches  apart. 

Exceptional. — In  deep  inspiration  the  lower  line  may  be  carried  an  inch  and  a  half 
or  two  inches  lower,  and  in  forcible  expiration  it  may  be  elevated  from  one  to  five 
inches,  therefore  the  area  of  hepatic  dulness,  between  the  two  lines,  may  vary  from 
two  inches  to  seven  or  eight  inches.  This  wide  range  is  not  common,  but  its  occasional 
occurrence  forcibly  illustrates  the  necessity  for  studying  the  chest  both  in  inspiration 
and  in  expiration. 

In  the  left  mammary  region  pulmonary  resonance  is  obtained 
over  the  outer  part.  Near  the  middle  portion  of  the  region 
forcible  percussion  elicits  cardiac  dulness.  .  Near  the  sternum 
the  heart  is  superficial,  covered  only  by  the  pericardium  and 
by  cellular  tissue ;  here  there  is  a  small,  flat,  triangular  space 
about  an  inch  and  a  half  in  width  at  its  base,  which  corresponds 
to  the  sixth  rib,  and  extending  from  the  fourth  to  the  sixth 
costal  cartilage.  The  apex  of  this  triangle  is  located  at  the 
margin  of  the  sternum  on  a  level  with  the  fourth  rib.  This 
space  is  caused  by  the  receding  border  of  the  left  lung,  which 
leaves  the  median  line  near  the  fourth  rib  and  passes  obliquely 
downward  and  outward  to  a  point  corresponding  nearly  to  the 
junction  of  the  sixth  costal  cartilage  with  its  rib. 

The  resonance  of  the  mammary  region  is  modified  more  or 
less  by  the  thickness  of  the  muscles  in  males,  and  by  the  mam- 
mary glands  in  females. 

In  the  infra-mammary  region,  on  the  right  side,  there  are  no 


PERCUSSION.  25 

organs  but  the  liver,  and  hence  we  have  resonance,  termed  flat- 
ness, like  that  obtained  by  percussing  on  the  thigh.  If  the 
colon  happens  to  be  distended  by  gas,  we  will  obtain  tympa- 
nitic  resonance  in  the  lower  part  of  this  region. 

In  the  infra-mammary  region  of  the  left  side  we  will  find  flat- 
ness extending  a  couple  of  inches  to  the  left  of  the  median  line, 
caused  by  the  left  lobe  of  the  liver.  In  the  outer  portion  of 
this  region  we  will  obtain  a  similar  sound  from  the  spleen,  and 
between  these  two  points  we  elicit  tympanitic  resonance  from 
the  stomach. 

In  the  upper  sternal  region,  as  low  as  the  level  of  the  second 
costal  cartilages,  the  sound  is  tubular,  or  according  to  Flint, 
tympanitic.  This  is  due  to  the  presence  of  the  trachea,  the 
sounds  of  which  are  modified  by  the  anterior  borders  of  the 
lungs  which  are  in  apposition  throughout  this  region.  Below 
the  second  ribs,  on  light  percussion,  pulmonary  resonance  may 
be  obtained,  though  modified  by  the  timbre  of  the  bone.  But 
on  deep  percussion  dulness  is  found,  resulting  from  the  pres- 
ence of  the  great  blood-vessels. 

Over  the  lower  portion  of  the  sternum — lower  sternal  re- 
gion— by  light  percussion  pulmonary  resonance  will  be  obtained 
to  the  right  of  the  median  line,  while  on  forcible  percussion 
there  is  dulness.  Left  of  the  median  line,  the  heart  is  superfi- 
cial and  yields  flatness.  At  the  inferior  portion  of  this  region, 
flatness  is  due  to  the  left  lobe  of  the  liver. 

Over  the  scapula,  the  vesicular  sound  is  indistinct,  owing  to 
the  thickness  of  the  muscular  tissue,  but  above  the  spine  of 
the  scapula,  it  is  much  more  marked  than  below,  and  in  the 
upper  part  of  this  region  it  is  quite  clear. 

Between  the  scapulae,  in  the  inter-scapular  regions,  the 
sounds  are  quite  hard  and  high-pitched,  because  the  chest-walls 
are  thick.  There  is,  however,  in  all  cases  a  little  pulmonary 
resonance.  The  note  is  a  trifle  higher  on  the  left  side,  on  ac- 
count of  the  aorta.  • 

In  the  infra-scapular  regions  the  vesicular  resonance  is  well 
defined,  though  not  quite  so  clear  as  in  the  infra-clavicular  re- 
gion. It  extends  downward  to  the  tenth  or  eleventh  rib.  On 
the  right  side,  we  find  the  line  of  hepatic  dulness  at  the  eighth 
rib,  and  the  line  of  hepatic  flatness  at  the  eleventh  rib ;  but 


^6  PULMONARY   DISEASES. 

these  vary  from  one  to  two  inches  during  forcible  respiration 
(Fig.  2,  page  4). 

On  the  left  side,  the  resonance  is  slightly  modified  near  the 
spine,  by  the  presence  of  the  liver.  Below  the  tenth  rib,  the 
intestinal  canal,  if  filled  with  gas,  causes  a  tympanitic  sound. 
In  the  outer  part  of  this  region,  between  the  ninth  and  the 
eleventh  ribs,  dulness  is  obtained  from  the  presence  of  the 
spleen,  and  for  a  short  distance  about  this  dull  region  the 
resonance  is  rendered  more  or  less  tympanitic  by  the  stomach 
and  the  intestines.  In  the  lower  part  of  the  left  infra-scapular 
region,  close  to  the  spinal  column,  dulness  is  found  over  the 
kidney,  and  in  a  similar  position,  though  a  trifle  lower,  it  occurs 
on  the  right  side. 

In  the  axillary  regions,  the  resonance  is  often  more  marked 
than  in  the  infra-clavicular  regions.  These  regions  contain 
vesicular  lung  tissue,  with  the  main  bronchi. 

In  the  infra-axillary  region,  the  resonance  is  modified  on  the 
right  side  by  the  liver,  and  upon  the  left  by  the  stomach  and 
spleen. 

In  this  region,  the  margin  of  the  lung  passes  obliquely 
downward  and  backward  from  the  anterior  portion  near  the 
sixth  rib,  to  the  posterior  border  near  the  tenth  rib.  On  the 
right  side,  hepatic  flatness  is  found  below  this  line,  and  hepatic 
dulness  a  couple  of  inches  higher.  On  the  left  side,  below 
this  line  we  find  tympanitic  resonance  in  front  over  the  stom- 
ach, and  dulness  posteriorly  over  the  spleen.  The  pulmonary 
resonance  is  often  modified  by  the  stomach,  in  this  region,  as 
high  as  the  fourth  rib. 

The  spleen  varies  considerably  in  its  size,  even  in  health. 
The  area  of  dulness  which  it  causes  seldom  exceeds  two 
and  one  half  inches  in  height ;  laterally  it  extends  about  four 
inches,  about  half  of  which  dull  space  is  in  the  infra-scapular 
and  half  in  the  infra-axillary  region. 

Exceptional  — In  rare  cases  *the  spleen  rises  as  high  as  the  lower  portion  of  the  axil- 
lary region,  or  the  stomach  may  yield  decided  tympanitic  resonance  as  high  as  the  fourth 
rib. 

In  the  infra-scapular  region,  upon  the  right  side  in  children,  dulness  is  sometimes 
very  pronounced,  due  to  the  disproportionate  size  of  the  liver  in  early  life.  This  is  not 
infrequently  mistaken  for  the  consolidation  of  pneumonia. 

The  percussion  sounds  in  different  regions  of  the  chest  are 


PERCUSSION. 


37 


modified  by  age,  sex,  and  by  various  idiosyncrasies.  In  old  age, 
the  chest-walls  are  not  so  elastic  as  in  middle  life,  and  the  lung 
tissue  has  undergone  some  change  which  renders  the  sounds 
harder  in  quality  and  higher  in  pitch,  or,  in  other  words,  less 
vesicular.  In  children,  the  lungs  are  very  resonant,  and  the 
costal  cartilages  are  elastic ;  consequently  we  obtain  a  low- 
pitched,  intense,  vesicular  sound.  In  males,  the  percussion 
note  over  the  upper  portion  of  the  chest  is  not  usually  so  reso- 
nant as  in  females,  but  it  is  more  distinct  over  the  lower  por- 
tions. It  will  be  seen,  from  what  has  already  been  said,  that 
there  is  notable  dissimilarity  of  the  percussion  sounds  on  the 
two  sides  in  the  mammary  regions,  as  also  in  the  infra-mam- 
mary, infra-axillary,  and  infra-scapular  regions.  In  all  other 
portions  of  the  chest,  the  resonance  is  nearly  identical  on  the 
two  sides,  but  the  slight  normal  disparity  in  the  infra-clavic- 
ular regions  is  a  point  of  great  importance. 


LECTURE   .IV. 
PERCUSSION   IN   DISEASE. 

In  disease,  the  percussion  sounds  of  which  I  have  been  speak- 
ing, may  pass  through  every  gradation  from  normal  to  tympa- 
nitic  resonance.  These  varieties  of  the  percussion  sound  have 
been  variously  classified  by  different  authors.  Dr.  R.  E. 
Thompson  classifies  them  as  clear,  dull,  tympanitic,  amphoric, 
and  "  cracked-pot"  resonance.  Dr.  Flint  arranges  them  under 
six  heads ;  and  Dr.  Loomis,  under  seven,  as  follows :  Exagger- 
ated pulmonary  resonance,  dulness,  flatness,  tympanitic  reso- 
nance, vesiculo-tympanitic  resonance,  amphoric  resonance,  and 
"  cracked-pot "  resonance,  or  the  cracked-metal  sound. 

EXAGGERATED  PULMONARY  RESONANCE  differs  from  the  nor- 
mal vesicular  sound  only  in  its  intensity.  The  pitch  and  qual- 
ity of  the  sound  are  exactlv  the  same  as  in  health,  but  the 
intensity  is  increased.  This  sound  is  obtained  over  lung-tissue 
which  is  receiving  more  than  the  ordinary  amount  of  air,  and 
which  might  therefore  be  said  to  be  in  the  highest  degree  of 
health. 

The  sign  is,  therefore,  only  negative,  as  it  points  to  no  disease 
whatever  in  the  place  where  it  is  obtained,  but  rather  it  points 
to  deficient  action  in  some  other  portion  of  the  respiratory 
tract.  Exaggerated  pulmonary  resonance,  obtained  in  the 
adult,  is  very  nearly  the  same  as  the  normal  resonance  in  chil- 
dren. The  sign  results  from  obstruction  to  the  entrance  of  air 
into  some  portion  of  the  respiratory  tract,  whether  from  filling 
up  of  the  air-cells  by  inflammatory  exudation,  as  in  pneumonia ; 
or  from  narrowing  of  the  bronchial  tubes ;  or  from  collapse  of 
the  air-cells.  Pneumonia  of  one  lung  or  of  a  single  lobe  of  a 
lung,  causes  exaggerated  resonance  over  healthy  portions  of 
the  lungs.  Compression  of  the  lung,  whether  it  be  by  air  or 
by  fluid  in  the  pleural  sac,  will  give  rise  to  exaggerated  reso- 
nance on  the  sound  side.  If  the  main  bronchus  is  occluded, 


PERCUSSION.  30 

whether  it  be  from  causes  within  the  bronchus  or  from  causes 
external  to  it,  the  resonance  is  exaggerated  on  the  opposite 
side.  In  extreme  anaemia,  we  get  exaggerated  resonance  on 
both  sides,  which  is  said  to  be  due  to  a  diminished  amount  of 
blood  in  the  pulmonary  circuit.  As  the  chest  is  practically  a 
cavity  with  unyielding  walls,  any  diminution  in  its  fluid  con- 
tents must  cause  a  corresponding  increase  in  the  amount  of  air. 

DULNESS  indicates  that  there  is  a  small  amount  of  air  be- 
neath the  part  percussed.  It  can  always  be  obtained  in  the 
healthy  chest  where  the  lung  overlaps  the  liver.  This  sign 
differs  from  normal  vesicular  resonance  in  pitch,  quality,  and 
duration.  Its  pitch  is  high,  its  quality  hard,  and  its  duration 
comparatively  short.  The  intensity  of  the  sound  is  usually 
less  than  that  of  the  vesicular  resonance.  Varying  degrees  of 
dulness  should  be  carefully  studied  on  the  healthy  chest.  Over 
the  liver,  on  forcible  percussion,  slight  dulness  is  found  in 
the  fourth  intercostal  space,  and  as  the  examination  is  extended 
downward,  the  sign  becomes  more  and  more  distinct,  becom- 
ing gradually  higher  in  pitch,  harder  in  quality,  and  shorter  in 
duration,  until  the  lower  margin  of  the  lung  is  reached. 

This  sign,  when  obtained  in  a  position  which  should  yield 
vesicular  resonance,  indicates  that  something  has  occurred  to 
diminish  the  normal  amount  of  air  in  that  portion  of  the  lung. 
It  is  a  sign  that  is  obtained  when  there  is  consolidation  of  the  lung, 
whether  it  be  from  simple  inflammation  or  from  phthisis,  from 
compression  of  the  lung  or  from  collapse  of  the  air-cells. 
Dulness  is  also  obtained  over  collections  of  fluid  in  the  bronchi 
or  in  the  air  vesicles,  as  in  pulmonary  oedema  and  hemorrhage  ; 
also  over  moderate  exudations  in  the  pleural  sac,  which  separate 
the  lung  from  the  chest-walls ;  but  effusions  of  any  consider- 
able amount  give  rise  to  another  sign,  known  as  flatness.  Dul- 
ness is  obtained  over  intra-thoracic  tumors,  whether  solid  or  fluid, 
provided  only  a  small  portion  of  lung  tissue  intervenes  between 
them  and  the  thoracic  wall.  This  is,  therefore,  one  of  the  signs 
which  can  be  found  in  pneumonia,  pleuritis,  phthisis,  atelectasis, 
and  in  intra-thoracic  abscesses,  aneurisms,  and  other  tumors. 

Exceptional. — It  results  occasionally  from  pulmonary  apoplexy.  In  such  cases  it 
is  usually  found  at  the  lower  angle  of  the  scapula.  It  may  arise  from  brown  indura- 
tion of  the  lung,  due  to  a  varicose  condition  of  the  pulmonary  veins.  In  this  disease 
it  is  found  near  the  middle  of  the  lungs  on  both  sides.  It  may  arise  from  enlarged 


4o  PULMONARY   DISEASES. 

bronchial  glands;  and  in  a  few  instances  this  sign  is  found  in  bronchitis  over  the  apex 
of  the  lungs;  or  more  marked  dulness  may  be  found  at  the  lower  posterior  part  of  the 
chest,  due  to  a  collection,  within  the  bronchi,  of  the  secretions  from  the  mucous 
membrane. 

FLATNESS. — Dulness  differs  from  flatness  in  that  it  still 
retains  something  of  the  vesicular  resonance.  Flatness  has  no 
pulmonary  resonance.  The  one  indicates  that  there  is  some 
air  beneath  the  point  at  which  the  stroke  is  made,  the  other 
that  there  is  none.  Dulness  is  obtained  over  that  portion  of 
the  liver  which  is  overlapped  by  lung  tissue ;  flatness,  from  that 
portion  below  the  sixth  rib,  which  is  superficial.  Dulness  is 
obtained  in  pleurisy  where  the  exudation  of  inflammatory 
lymph  has  separated  the  lung  a  short  distance  from  the  chest- 
wall  and  caused  a  corresponding  diminution  in  the  volume  of 
air.  Flatness  will  be  found  in  the  same  disease,  when  an  effu- 
sion of  serum  lifts  the  lung  above  it  and  consequently  removes 
all  of  the  air-containing  tissue  from  beneath  the  point  percussed. 

Flatness  is  found  in  pleurisy  with  effusion  oftener  than  in 
any  other  disease. 

Exceptional. — In  a  few  rare  cases  of  pneumonia,  the  inflammation  runs  to  such  height 
that  not  only  the  air  cells,  but  also  the  bronchial  tubes  are  filled  with  the  exudation, 
and  in  such  cases  absolute  flatness  will  be  found  over  the  lung  tissue.  Again,  when  the 
lung  becomes  completely  collapsed  from  pressure,  or  obstruction  of  a  large  bronchus, 
flatness  results. 

Tumors  or  abscesses  within  the  thorax,  when  they  rest  against 
the  chest-walls,  cause  flatness. 

TYMPANITIC  RESONANCE  is  the  name  given  to  the  sound 
which  may  be  normally  obtained  over  the  stomach  or  the  in- 
testines when  filled  with  air  or  gas. 

Under  certain  conditions,  this  sign  is  met  with  over  the 
thorax.  Tympanitic  resonance  is  usually  described  as  of 
higher  pitch  than  the  vesicular  sound.  Its  duration  may  be 
longer  or  shorter,  and  its  quality  is  hollow,  conveying  the  idea 
of  more  or  less  tension  ;  it  is  also  somewhat  hard,  metallic,  and 
ringing.  We  find  conflicting  statements,  by  different  authors, 
concerning  the  pitch  of  this  sign.  Some  hold  that  it  is  high, 
others  that  it  is  low-pitched.  The  disparity  seems  due  to  a 
difference  in  the  musical  sense  or  training  of  various  observers  ; 
musicians  would  doubtless  have  no  difficulty  in  deciding.  It 
seems  to  me  that  the  discrepancy  has  arisen  from  mistaking 


PERCUSSION.  4I 

the  ringing,  hollow  quality  of  the  sound  for  a  high  pitch,  when 
it  may  really  be  low.  I  find  the  weight  of  opinion  in  favor  of 
a  high  pitch.  Dr.  R.  E.  Thompson,  in  his  little  work  on  the 
physical  examination  of  the  chest,  states  that  the  pitch  of  this 
sign  may  be  either  high  or  low ;  high  when  the  tension  of  the 
volume  of  air  is  great,  and  low  vnjien  it  is  slight. 

This  variety  of  resonance  is  never  found  in  the  healthy  chest, 
unless  it  be  transmitted  from  some  of  the  organs  beneath  the 
diaphragm  ;  but  it  is  frequently  obtained  in  normal  conditions  of 
the  thoracic  organs,  below  the  fourth  rib,  on  the  left  side,  as 
the  result  of  distention  of  the  stomach  or  the  intestines  with 
gas.  It  is  occasionally  obtained  over  the  infra-mammary  region 
on  the  right  side  when  the  colon  is  distended.  When  it  is 
obtained  over  portions  of  the  chest  which  should  yield  a  vesic- 
ular sound,  the  sign  is  usually  indicative  of  a  collection  of  air 
or  of  gas  in  the  pleural  sac,  as  in  pneumothorax.  Occasionally 
it  is  found  over  a  large  cavity  in  the  lung  tissue  containing  air. 

Pulmonary  cavities  are  generally  produced  by  phthisis ; 
therefore  we  lay  down  as  a  rule,  that  there  are  only  two  dis- 
eases of  the  chest  in  which  this  sign  is  found,  viz.,  pneumothorax 
and  phthisis. 

Exceptional. — It  is  claimed  by  Guttman,  Gee,  and  some  others  that  this  variety  of 
resonance  sometimes  results  from  diminished  tension  of  the  pulmonary  parenchyma,  and 
that  it  may  be  found  in  any  of  those  conditions  causing  partial  collapse  of  the  lung. 

Perfect  tympanitic  resonance  may  be  obtained  in  that  very  rare  condition  in  which  air 
or  gas  collects  in  the  pericardium.  It  is  said  to  be  found  in  some  cases  of  emphysema 
and  of  acute  tuberculosis. 

Tympanitic  resonance  from  the  stomach  may  be  elicited  far 
above  its  normal  seat,  when  the  lung  is  retracted  and  the 
stomach  and  intestines  are  correspondingly  elevated. 

VESICULO-TYMPANITIC  RESONANCE  is  a  quality  of  sound 
midway  between  the  vesicular  and  the  tympanitic. 

This  sign  occurs  in  extreme  emphysema,  where  the  air-cells 
and  the  chest-walls  are  distended. 

AMPHORIC  RESONANCE  is  a  sound  which  may  be  closely 
imitated  by  tapping  the  cheek  gently  when  the  mouth  is  filled 
with  air,  but  not  much  distended.  The  sound  is  hollow,  and 
somewhat  metallic.  It  is  obtained  in  very  much  the  same  con- 
ditions as  "  cracked-pot"  resonance — that  is,  over  an  empty 
pulmonary  cavity  with  yielding  walls ;  but  to  produce  this 


42  PULMONARY  DISEASES. 

sign  the  cavity  must  communicate  freely  with  a  large  bronchial 
tube,  so  that  the  air  can  be  driven  quickly  from  it  by  the  per- 
cussion stroke.  It  is  found  also  over  collections  of  air  in  the 
pleural  sac,  when  this  cavity  opens  through  the  lung  into  a 
large  bronchus. 

Pulmonary  cavities  are  gfnerally  caused  by  phthisis,  but 
they  may  result  from  abscess.  Amphoric  resonance  is  there- 
fore a  sign  of  pneumothorax,  phthisis,  and  possibly  of  abscess  or 
of  gangrene. 

Bell  Sound.  While  listening  over  a  large  pulmonary  cavity,  if 
percussion  be  made  on  the  opposite  side  of  the  chest,  with  one 
large  coin  striking  upon  another  used  as  a  pleximeter,  a  ringing 
bell  sound  will  be  heard,  which  is  sometimes  very  loud. 

CRACKED-POT  RESONANCE  (bruit  de  pot  fclc). — This  sign  may 
be  imitated  by  placing  the  hands  loosely  together,  palm  upon 
palm,  and  striking  upon  the  knee.  It  is  described  as  resem- 
bling the  clinking  of  coin  or  the  timbre  of  a  cracked  metallic 
kettle.  Generally  the  sign  seems  to  be  the  result  of  forcing 
air  suddenly  from  a  pulmonary  cavity  through  a  small  opening. 
This  sound  has  been  considered,  by  some  authors,  as  diagnostic 
of  a  pulmonary  cavity ;  but  this  is  a  mistake,  for  the  sign  may 
occasionally  be  obtained  when  no  cavity  exists,  and  sometimes 
even  in  healthy  individuals.  Something  closely  resembling 
this  resonance  is  very  likely  to  be  heard  during  percussion  if 
the  pleximeter  is  placed  lightly  against  the  surface,  so  that  air 
remains  beneath  it  which  is  suddenly  forced  out  by  the  blow. 

It  is  said  that  occasionally  this  sound  may  be  elicited  in  the  bronchitis  of  children, 
or  just  above  the  level  of  the  fluid  in  pleurisy  with  effusion. 

As  a  rule,  cracked-pot  resonance  is  a  sign  of  a  cavity,  but  the 
majority  of  cavities  do  not  produce  it.  The  sign,  where  found, 
can  seldom  be  heard  more  than  two  or  three  times  together, 
and  it  requires  an  interval  of  rest  before  it  can  be  reproduced. 
This  is  probably  due  to  the  small  opening  into  the  cavity — the 
air,  having  been  driven  out,  returns  slowly. 

THE   PLESSIGRAPH. 

Before  leaving  the  subject  of  percussion,  I  wish  to  call  your 
attention  to  a  little  instrument  known  as  the  plessigraph, 
which  was  devised  by  Dr.  Michael  Peter,  of  Paris.  In  per- 


THE   PLESSIGRAPH.  43 

cussion  with  the  ordinary  pleximeter,  no  matter  what  its 
material  or  its  form  of  construction,  all  the  tissue  beneath  it  is 
thrown  into  vibration.  This  renders  it  next  to  impossible  to 
define  sharply  the  outlines  of  dulness  when  solid  tissue  is  over- 
lapped by  the  lung,  because  the  pleximeter  covers  too  much 
space,  and  the  sounds  from  the  tissues  containing  air  and  from 
those  which  do  not  are  blended.  For  instance,  in  attempting 
to  determine  the  lower  border  of  the  lung,  where  it  over- 
laps the  liver,  we  commence  above  and  percuss  downwards 
till  we  get  complete  flatness,  then  upwards  again  to  a  point 
where  the  vesicular  resonance  is  clear,  and  thus  back  and  forth, 
until  two  adjacent  points  are  reached  where  we  obtain  6n 
the  one  hand  quite  perfect  pulmonary  resonance,  and  on  the 
other,  flatness.  Then  we  judge  that  the  border  of  the  lung 
lies  midway  between  the  two. 

To  avoid  throwing  too  much  tissue  into  vibration,  the  size  of 
the  pleximeter  must  be  abridged  ;  but  as  the  size  is  diminished, 
unless  compensated  for  in  some  way,  the  intensity  of  the  sound 
is  correspondingly  lessened.  These  difficulties  seem  to  have 
been  overcome  in  the  construction  of  the  plessigraph. 

This  instrument  consists  of  a  small  cylindrical  piece  of  wood, 
about  four  inches  in  length,  and  five  eighths  of  an  inch  in 
diameter,  with  a  disk  at  one  end  upon  which  percussion  is  to 
be  made.  The  other  end  consists  of  a  truncated  cone,  the 
plane  surface  of  which  measures  nearly  an  eighth  of  an  inch 
in  diameter.  In  using  the  instrument,  the  small  end  is  placed 
on  the  surface  of  the  chest,  and  percussion  is  made  upon  the 
other  end,  with  the  pulp  of  a  single  finger.  Care  must  be  taken 
that  the  instrument  is  held  perpendicular  to  the  surface.  On 
account  of  the  smallness  of  the  surface  which  rests  against  the 
chest,  the  sound  obtained  would  be  very  feeble,  were  it  not  in 
a  measure  intensified  by  the  body  of  the  instrument,  which  acts 
as  a  sounding-board.  Trousseau  tells  us  that  it  is  not  neces- 
sary to  strike  upon  the  disk,  but  that  we  may  simply  tap  upon 
it  with  the  pulp  of  the  finger.  He  states  that,  by  means  of  this 
instrument,  even  students  may  rapidly  map  out  the  liver  or 
heart,  when  with  ordinary  percussion  this  might  be  impossible, 
even  for  a  skilled  diagnostician.  The  instrument  as  constructed 
by  Dr.  Peter,  had  upon  the  side  an  arrangement  holding  a 
crayon  which  could  be  pressed  down  to  mark  the  skin  when 


44  PULMONARY  DISEASES. 

the  border  of  the  lung  had  been  found,  so  that,  when  through 
percussing,  a  dotted  line  would  be  left  corresponding  to  the 
outlines  of  the  solid  viscus  or  tumor.  I  have  found  this  instru- 
ment very  satisfactory  in  determining  superficial  dulness,  so 
long  as  it  is  employed  only  in  the  intercostal  spaces,  but  not 
when  applied  over  the  ribs. 

AUSCULTATORY  PERCUSSION. 

This  method  of  percussion  was  instituted  by  Drs.  Camman 
and  Clark  in  1840.  It  consists,  as  the  name  implies,  of  com- 
bined auscultation  and  percussion.  In  practicing  it,  a  stetho- 
scope is  needed.  For  this  purpose  the  originators  of  the 
method  devised  a  peculiar  instrument,  which  consists  of  a 
solid  cylinder  of  wood  formed  at  one  end  into  a  truncated 

wedge,  and  at  the  other  into  a 
disk  (Fig.  1 1).  In  using  the 
instrument,  the  wedge-shaped 
extremity  is  placed  upon  the 
FIG.  ii. — Camman's  Stethoscope  for  surface,  in  an  intercostal  space, 

Auscultatory  Percussion.  oyer    tne    most    superficial    por- 

tion  of  the  organ  or  tumor  to  be  examined,  and  the  examiner's 
ear  is  placed  upon  the  disk.  An  assistant  is  then  directed  to 
percuss  from  the  healthy  lung  tissue  toward  the  instrument. 
The  moment  percussion  is  made  over  solid  tissue,  the  changed 
sound  will  at  once  reveal  the  fact  to  the  listener,  and  thus  en- 
able him  to  determine  the  deep  outlines  of  the  solid  mass  much 
more  accurately  than  by  ordinary  percussion.  The  ordinary 
binaural  stethoscope  with  the  smaller  chest-piece  may  be  used 
for  the  same  purpose.  The  advantages  claimed  for  this  method 
of  examination  are,  that  it  enables  persons  to  map  out  intra- 
thoracic  tumors  or  to  determine  the  outlines  of  the  heart  or  of 
the  liver  much  more  accurately  and  rapidly  than  by  other 
means.  Outlines  of  the  liver,  the  spleen,  and  the  kidney  may 
be  ascertained  with  considerable  accuracy,  even  when  ascites 
is  present. 

One  serious  obstacle  has  been  found  to  the  practice  of  this 
method,  namely,  a  second  person  is  necessary  to  make  the  per- 
cussion, and  it  is  often  impossible  to  get  a  skilled  assistant  at 
the  time  we  need  one.  To  overcome  this  difficulty,  I  have 
devised  an  instrument  known  as  the  Emballometer  (Fig.  12).  It 


AUSCULTATORY   PERCUSSION.  45 

consists  of  a  hollow  cylinder  about  three  inches  in  length  by  five 
eighths  of  an  inch  in  diameter,  within  which  plays  a  metallic 
plunger.  To  the  objective  end  of  the  instrument  is  fitted  a  soft- 
rubber  chest-piece,  against  which  the  plunger  strikes.  To  the 
other  end  is  attached  a  rubber  tube  about  eighteen  inches  in 
length,  which  connects  it  with  a  rubber  bulb.  Compression  of 
the  rubber  bulb  drives  the  plunger  against  the  chest-piece ;  at 
the  instant  the  pressure  is  removed,  the  bulb  expands  and  the 
plunger  is  forced  upward  by  atmospheric  pressure.  In  prac- 
ticing auscultatory  percussion  by  the  aid  of  this  instrument, 


FIG.  12. — Ingals'  Emballometer. 

the  stethoscope  is  held  with  the  left  hand ;  the  bulb  of  the  em- 
ballometer  is  held  in  the  palm  of  the  right  hand  by  the  last 
three  fingers,  and  the  cylinder  is  held  by  the  thumb  and  fore- 
finger. This  enables  the  physician  to  move  the  instrument 
without  restraint,  to  strike  any  point  as  rapidly  or  as  slowly  as 
he  chooses,  and  with  whatever  force  may  be  desirable.  You  will 
observe  that  I  can  strike  with  great  rapidity  if  I  desire,  and 
that  I  can  give  a  light  tap  or  a  blow  which  may  be  heard  all  over 
this  amphitheatre.  By  means  of  this  little  instrument  and  the 
binaural  stethoscope,  auscultatory  percussion  can  be  satisfac- 
torily practiced  without  the  aid  of  an  assistant.  In  using  the 
binaural  stethoscope  for  this  purpose,  the  small  chest-piece 
should  be  employed,  and  probably  one  still  smaller  or  one  flat- 
tened, so  that  it  might  be  applied  between  the  ribs,  would  give 
even  better  results. 


LECTURE    V. 
AUSCULTATION. 

Auscultation,  or  the  art  of  listening  to  the  sounds  produced 
within  the  chest,  originated  in  the  early  part  of  the  present 
century ;  it  ranks  first  among  the  methods  for  physical  explo- 
ration. The  sounds  to  be  studied  by  this  method  are  produced 
during  either  inspiration  or  expiration,  or  during  both  portions 
of  the  respiratory  act. 

There  are  two  methods  of  auscultation,  known  as  mediate 
and  immediate.  In  mediate  auscultation,  the  sounds  are  con- 
ducted to  the  ear  through  an  instrument  known  as  the  stetho- 
scope. Immediate  auscultation  is  practiced  by  placing  the  ear 
directly  on  the  surface  of  the  chest,  or  on  the  chest  but  slightly 
covered.  The  first  of  these  methods  is  the  one  which  was  first 
introduced  to  the  profession  in  the  year  eighteen  hundred  and 
sixteen.  In  this  connection,  a  brief  notice  of  Laennec,  the 
inventor,  may  be  interesting.  He  was  born  in  an  obscure 
province  in  France,  and  at  the  age  of  nineteen  went  to  Paris 
to  obtain  his  medical  education,  where  he  very  soon  attracted 
the  attention  of  the  profession  by  his  diligence  and  attentive- 
ness  at  the  hospitals.  These  studious  habits  ere-long  opened 
places  which  enabled  him  to  prosecute  his  investigations  with 
vigor  and  success. 

From  the  time  that  he  entered  Paris  until  his  final  departure, 
about  five  years  before  his  death,  his  whole  life  seems  to  have 
been  given  to  careful  clinical  study,  and  verification  of  the 
results  in  the  necropsy  theatre.  The  fruit  of  this  labor  we 
find  in  papers  written  by  him,  on  inflammation,  melanosis,  en- 
cephaloid  cancer,  and  numerous  other  topics,  but  especially  in 
the  great  work  of  his  life,  his  treatise  on  auscultation.  This 
treatise  was  published  in  1816,  when  the  author  was  about  thirty- 
five  years  of  age.  It  was  the  introduction  of  auscultation  to 
the  profession,  and  its  author  was  so  thorough  and  his  conclu- 


AUSCULTATION.  47 

sions  so  accurate,  that  since  his  day  it  has  been  hardly  possible 
to  add  to  the  information  upon  this  subject  which  he  gathered 
and  bequeathed  to  us.  Not  long  after  he  published  this  work, 
close  application  began  to  undermine  his  health,  and  in  a  few 
years  the  very  method  which  he  had  introduced  disclosed  the 
signs  of  phthisis  in  his  own  chest.  Realizing  fully  the  importance 
of  these  signs,  he  resigned  his  work  in  Paris  and  retired  to  his 
native  province,  where  he  died  at  the  age  of  forty -five,  leaving 
a  name  which  will  be  remembered  when  most  of  those  now 
prominent  have  sunk  into  oblivion.  Since  his  death,  the  method 
known  as  immediate  auscultation,  which  Laennec  states  was 
first  practiced  by  Boyle,  has  received  great  favor  with  the  pro- 
fession. At  the  present  time,  many  physicians  consider  this 
the  only  proper  method  of  auscultation,  while  there  are  a  few 
others  who  rely  entirely  upon  the  mediate  method.  Whatever 
the  advantages  of  either  may  be,  you  must  become  familiar 
with  both  if  you  wish  to  be  accurate  diagnosticians. 

There  are  some  objections  to  the  use  of  the  stethoscope. 
The  first  and  main  objection  is,  that  it  has  a  peculiar  ringing 
sound,  which  is  always  confusing  to  beginners.  Until  you  be- 
come sufficiently  familiar  with  the  instrument  to  ignore  this, 
you  will  be  unable  to  appreciate  the  pulmonary  sounds. 
Another  prominent  objection  is  that  many  of  these  instruments 
are  poorly  constructed,  and  are  consequently  worthless.  The 
stethoscope  is  of  very  little  value  in  examining  children, 
because  it  is  likely  to  frighten  them ;  besides,  the  respiratory 
murmur  in  them  is  so  loud  that  it  can  be  easily  heard  with  the 
unaided  ear. 

In  examining  the  lungs,  the  ear  alone  is  sufficient ;  but  when 
we  wish  to  differentiate  between  the  sounds  produced  at  the 
various  orifices  of  the  heart,  we  must  employ  the  stethoscope, 
the  small  chest-piece  of  which  excludes  in  a  great  measure  all 
sounds  excepting  those  produced  immediately  beneath  it. 

Some  of  the  advantages  of  mediate  auscultation  are :  it  greatly 
intensifies  the.  intra-thoracic  sounds,  so  that  signs  which  could 
not  be  heard  at  all  by  the  unaided  ear,  may  be  readily  recog- 
nized through  the  instrument ;  some  portions  of  the  chest  can- 
not be  easily  examined  by  immediate  auscultation — for  instance, 
in  the  axillary  space  and  in  the  region  just  above  the  clavicle  ; 
therefore,  the  instrument  becomes  necessary  ;  again,  there  are 


48  PULMONARY   DISEASES. 

instances  where  it  would  be  unpleasant  to  apply  the  ear  to  the 
chest,  and  others  where,  for  the  sake  of  delicacy,  it  would  not 
be  advisable. 

The  advantages  claimed  for  immediate  auscultation  are :  it 
yields  no  humming  sound  ;  it  obviates  the  necessity  of  carrying 
an  instrument;  it  does  not  frighten  little  children,  and  the  re- 
sults obtained  are  usually  sufficiently  accurate. 

If  the  stethoscope  moves  slightly  upon  the  chest,  it  produces 
a  grating  sound  much  more  intense  than  the  respiratory  mur- 
mur. The  same  thing  occurs  if  the  finger  moves  upon  the 
instrument,  if  the  hand  is  drawn  over  the  surface  of  the  chest, 
or  if  the  patient's  clothes  move  upon  the  chest  or  upon  the 
instrument.  In  some  cases,  neither  mediate  nor  immediate  aus- 
cultation alone  yields  accurate  results,  while  the  two  combined 
enable  us  to  make  a  proper  diagnosis. 

There  is  now  a  great  variety  of  stethoscopes.  They  may 
be  classified,  however,  under  two  heads,  solid  and  flexible 
some  of  which  are  binaural  and  others  single.  The  binaural 


FIG.  13. — Solid  wooden  stethoscope. 

instrument  is  provided  with  two  tubes  which  conduct  the 
sound  simultaneously  to  both  ears.  The  single  stethoscope 
is  designed  only  for  one  ear.  The  solid  stethoscope  most 
in  use  is  a  tubular  instrument,  about  six  inches  in  length, 
which  is  generally  turned  from  a  single  block  of  wood.  It 
is  expanded  at  one  end  into  a  bell-shaped  chest-piece  about 
an  inch  and  a  fourth  in  diameter.  At  the  other  extremity  is 
a  disk  or  ear-piece  about  two  inches  in  diameter  (Fig.  13). 
Some  of  these  instruments  are  so  made  that  the  ear-piece  may 
be  removed  for  convenience  in  carrying,  and  have  a  soft-rubber 
ring  encircling  the  disk,  so  that  it  may  be  used  as  a  hammer 
in  percussion.  I  think  physicians  generally  find  more  difficulty 
in  examining  the  chest  with  this  instrument  than  with  the 
binaural  stethoscope.  A  binaural  stethoscope  was  devised  by 
Dr.  Leared,  of  London,  about  the  time  the  one  in  common  use 
was  invented  by  Dr.  Camman,  of  New  York.  Dr.  Leared's 


AUSCULTATION. 


49 


stethoscope  was  made  of  gutta-percha  and  consisted  of  two 
tubes,  one  for  each  ear.  The  auricular  extremities  of  these  tubes 
were  disk-shaped,  and  the  other  ends  were  fitted  in  a  hollow 
cylindric,  or  cup-shaped,  chest-piece.  The  elasticity  of  the 
tubes  kept  the  disks  in  firm  apposition  with  the  ears.  This  in- 
strument was  exhibited  in  London  in  the  year  eighteen  hundred 
and  fifty-one,  but  it  attracted  little  attention.  About  the  same 
time  Dr.  Carnman,  of  New  York,  introduced  the  binaural 
instrument  that  bears  his  name.  This  consists  of  two  metal 
tubes  so  curved  as  to  fit  into  both  ears  and  connected  with  each 
other  by  a  hinge-joint.  These,  when  placed  in  the  ears,  are 
held  in  position  by  an  elastic  which  passes  from  one  to  the 
other  just  above  the  joint,  or  by  springs  of  various  contrivance. 


FIG.  14. — Knight's  Stethoscope. 


The  auricular  ends  of  these  tubes  are  tipped  with  gutta-percha 
or  ivory,  of  sufficient  size  to  close  the  external  meatus,  and 
prevent  the  entrance  of  external  sounds.  To  the  other  ends 
are  fitted  two  flexible  tubes  which  connect  them  with  the  body 
of  the  instrument  to  which  the  chest-piece  is  attached  (Fig.  14). 
Each  of  these  instruments  has  two  chest-pieces,  one  about  an 
inch  and  a  quarter  in  diameter,  for  examination  of  the  lungs, 
the  other  five  eighths  of  an  inch  in  diameter,  for  the  examination 
of  the  heart.  With  many  instruments  a  soft-rubber  chest-piece 
is  furnished  which  may  be  fitted  over  the  end  of  the  smaller  of 
these,  and  is  designed  for  the  examination  of  emaciated  patients. 
This  chest-piece,  however,  is  practically  worthless  on  account 
of  the  creaking  which  is  produced  during  the  respiratory  move- 
4 


50  PULMONARY   DISEASES. 

ments,  by  friction  with  the  wooden  chest-piece  on  which  it  is 
adjusted.  An  instrument  known  as  the  differential  stethoscope 
was  invented  by  Dr.  Scott  Allison.  It  is  essentially  the  same 
as  Camman's,  with  the  exception  that  the  flexible  tubes  are 
each  fitted  with  a  distinct  chest-piece,  so  that  sound  can  be 
conducted  to  the  two  ears  simultaneously  from  different  por- 
tions of  the  chest  (Fig.  15).  Of  the  various  modifications  of 
Camman's  stethoscope,  the  one  known  as  Knight's  is  the  best. 
It  possesses  all  of  the  essential  points  of  a  good  instrument,  viz., 
the  metallic  ear-tubes  are  curved  at  the  proper  angle  to  conduct 
the  sound  directly  into  the  auditory  canal ;  the  ear-tips  are  of 
proper  size  to  exclude  external  sounds  and  are  not  so  small  as 
to  pass  into  the  auditory  canal  and  thus  occasion  pain ;  the 
flexible  tubes  which  connect  the  ear-pieces  with  the  chest-piece 


FlG.  15. — Allison's  Differential  Stethoscope. 

are  very  pliable  and  have  a  calibre  equal  to  that  of  other  por- 
tions of  the  instrument;  the  chest-pieces  are  of  proper  size,  and 
the  whole  instrument  is  thoroughly  finished. 

I  have  found  that  a  stethoscope  which  will  fit  one  person 
perfectly  and  allow  the  sounds  to  be  conducted  without  ob- 
struction into  the  auditory  canal,  with  another  may  rest  against 
the  external  ear  in  such  a  position  as  nearly  to  occlude  the 
orifice  of  the  ear-piece.  The  larger  chest-piece  ought  never 
to  exceed  one  and  one  fourth  inches  in  diameter.  If  larger 
than  this,  it  cannot  be  accurately  applied  to  an  emaciated  pa- 
tient; consequently  air  will  pass  beneath  it,  and  produce  a 
humming  sound,  which  will  drown  the  pulmonary  signs.  The 
apparatus  on  Knight's  stethoscope  for  adjusting  the  pressure  of 
the  ear-pieces  works  perfectly,  and  is  often  very  useful,  though 
a  simple  rubber  band  of  proper  strength  would  answer  the 
purpose,  if  only  one  person  were  using  the  instrument.  A 
rubber  band,  which  could  be  lengthened  or  shortened  by 


AUSCULTATION.  5! 

a  buckle,  would  allow  the  instrument  to  be  easily  adjusted  to 
any  head,  and  would  be  less  expensive. 

Considerable  practice  is  required  in  order  to  perform  aus- 
cultation properly.  That  you  may  become  expert  the  more 
readily,  I  wish  to  call  your  attention  to  a  few  rules. 

In  the  first  place,  in  mediate  auscultation  the  chest  must  be 
bared  ;  in  immediate  auscultation,  the  covering  must  be  as  soft, 
thin,  and  smooth  as  possible. 

The  position  of  both  patient  and  examiner  should  be  easy 
and  unrestrained.  If  the  patient  is  in  bed,  it  is  preferable  to 
have  him  sitting,  if  his  health  will  permit.  If  the  examiner  is 
in  an  uncomfortable  position,  he  cannot  properly  concentrate 
his  attention  upon  the  sounds. 

In  examining  a  child,  or  a  patient  in  bed,  it  is  a  good  plan  to 
rest  on  one  knee,  so  that  the  head  will  not  be  on  a  plane  lower 
than  the  body,  otherwise  the  gravitation  of  blood  to  the  brain 
will  cause  fulness  of  the  head  and  dizziness,  and  will  obtund 
the  sense  of  hearing. 

You  must  early  learn  to  concentrate  your  whole  attention 
on  the  sound  to  which  you  are  listening. 

It  is  desirable  to  have  the  room  as  quiet  as  possible,  espe- 
cially if  you  are  practicing  immediate  auscultation,  for  then  the 
ear  which  is  not  applied  to  the  chest  is  waiting  to  catch  every 
extraneous  sound.  In  immediate  auscultation  it  is  well  to  stop 
the  ear,  which  is  not  applied  to  the  chest,  with  the  finger. 

The  ear  or  the  stethoscope  should  be  applied  firmly,  but  not 
with  great  force,  to  the  surface,  and  in  such  manner  that  no 
air  can  pass  beneath  it. 

Compare  corresponding  portions  of  the  two  sides  with  each 
other,  during  both  natural  and  deep  respirations.  If  one  side 
is  examined  during  ordinary  or  forcible  respiration,  the  other 
must  be  examined  under  the  same  conditions. 

The  pulmonary  sounds  are  not  exactly  alike  in  any  two  in- 
dividuals, nor  are  they  the  same  in  different  regions  of  the 
chest,  in  the  same  individual ;  therefore,  it  is  necessary  to 
study  healthy  cases  carefully,  in  order  to  familiarize  yourselves 
with  all  varieties  of  healthy  sounds.  This  familiarity  must  be 
so  perfect  that  no  effort  of  the  mind  is  required  to  remember 
the  variations  in  different  localities.  I  cannot  urge  this  too 
forcibly,  because,  until  you  can  easily  recognize  the  healthy 


COLLIEISII 


52  PULMONARY  DISEASES. 

sounds,  it  is  absolutely  useless  for  you  to  attempt  to  detect  the 
signs  of  disease. 

PHYSIOLOGICAL  ACTION  or  THE  RESPIRATORY  ORGANS. 

When  the  blood  leaves  the  right  side  of  the  heart  surcharged 
with  carbonic  acid  and  other  debris  of  tissue  metamorphosis 
throughout  the  body,  it  makes  a  peculiar  impression  upon  the 
respiratory  nerves,  which  is  transmitted  to  the  brain  as  a  call 
for  more  oxygen.  Instantly  a  message  is  flashed  back  to  the 
inspiratory  muscles  over  the  nerves,  which  causes  them  to 
contract.  By  this  action  the  diaphragm  is  shortened  and  its 
convexity  is  lessened ;  the  ribs  are  lifted,  and  by  rotation  on 
their  articulations  with  the  spinal  column  they  are  at  the  same 
time  carried  forward  and  outward.  Thus  the  diameters  of 
the  chest  are  increased  in  every  direction,  and  the  air  rushing 
in  through  the  open  glottis  distends  the  elastic  lungs,  so  as  to 
keep  pace  with  the  expansion  of  the  chest.  Immediately  the 
respiratory  act  ceases,  the  muscles  relax,  the  elastic  tissue  of 
the  lung  asserts  itself,  and  the  air  is  expelled  from  the  pulmo- 
nary vesicles.  This  latter  is  a  passive  action,  in  which  the 
expiratory  muscles  take  little  part,  excepting  in  forcible  ex- 
piration. 

While  inspiration  is  taking  place,  we  hear  a  soft  breezy  or 
rustling  sound,  which  is  known  as  the  inspiratory  murmur. 
As  soon  as  it  ceases,  a  sound  soft  and  breezy,  but  less  intense 
and  much  shorter,  occurs,  which  is  the  expiratory  murmur. 
This  is  followed  by  a  period  of  rest,  which  completes  the  cycle 
of  respiration. 

AUSCULTATION  IN  HEALTH. 

A  variety  of  signs  may  be  obtained  in  the  normal  chest  owing 
to  the  position  of  surrounding  organs,  and  the  difference  in  the 
force  and  volume  of  the  current  of  air  producing  the  sounds. 

Auscultatory  sounds  are  possessed  of  elements  similar  to  those 
found  in  the  percussion  note,  viz.,  intensity,  pitch,  quality,  dura- 
tion ;  and  to  these  we  will  add  rhythm.  The  latter  refers  to  the 
relation  which  the  different  portions  of  the  respiratory  act  bear 
to  each  other.  The  intensity  of  the  sound  varies  in  different  peo- 
ple. The  pitch  and  the  quality  are  practically  the  same  in  all 
healthy  cases. 


AUSCULTATION.  53 

The  duration  of  the  sound  also  varies  in  different  cases,  but 
is  about  equal  to  the  duration  of  the  respiratory  act  which 
produces  it.  All  modifications  of  the  respiratory  murmur  which 
may  be  obtained  in  different  regions  of  the  chest  are  simply 
alterations  in  one  or  more  of  these  elements.  Thus,  in  different 
portions  of  the  respiratory  tract,  we  will  obtain  the  nor- 
mal vesicular  murmur,  bronchial  breathing,  and  tracheal  and 
laryngeal  respiration,  each  of  which  differs  from  the  others 
more  or  less  in  intensity,  pitch,  quality,  duration  and  rhythm. 
The  most  perfect  vesicular  murmur  is  obtained  in  the  infra- 
clavicular  and  infra-scapular  regions.  Bronchial  respiration, 
or  more  properly  broncho-vesicular  respiration,  may  be  heard 
over  the  bronchial  tubes,  and  for  an  inch  or  more  about  them 
in  every  direction,  either  upon  the  anterior  or  upon  the  pos- 
terior surface  of  the  chest.  Laryngeal  and  tracheal  respira- 
tion are  essentially  the  same.  They  are  obtained  over  the 
larynx  and  the  trachea. 

THE  VESICULAR  MURMUR,  which  is  the  sound  obtained  over 
the  pulmonary  parenchyma,  is  taken  as  the  standard  of  com- 
parison for  all  others.  This  sound  may  be  best  studied  in 
the  infra-scapular  region,  though  it  is  more  intense,  in  front, 
below  the  clavicle ;  but  in  the  latter  position  the  heart  sounds 
interfere  with  its  easy  recognition.  The  vesicular  murmur, 
like  all  other  respiratory  sounds,  is  possessed  of  two  parts. 
The  first  of  these,  the  inspiratory,  begins  as  a  soft  and  distant 
blowing  sound,  and  gradually  increases  in  intensity  and  ap- 
proaches more  nearly  to  the  ear  toward  the  end  of  the  act, 
when  it  is  breezy  or  rustling  in  character.  It  varies  in  inten- 
sity in  different  individuals,  but  it  is  generally  easily  heard. 
Its  pitch  is  low,  in  duration  it  corresponds  with  the  inspiratory 
act.  Its  quality  is  named  vesicular,  but  cannot  be  accurately 
described,  though  it  may  be  easily  learned  by  practice  upon  a 
healthy  chest.  This  sound  is  followed  immediately  by  a  gentle 
rustling  sound,  the  expiratory  murmur,  which  passes  off  gradu- 
ally into  a  low  breath  or  puff.  It  is  less  intense  than  the 
preceding,  being  usually  so  feeble  that  it  must  be  listened  for 
very  attentively;  it  is  of  the  same  low  pitch,  and  of  about  one 
fourth  of  the  duration  of  the  inspiratory  sound.  Though 
termed  vesicular,  its  quality  is  neither  strictly  vesicular  nor 
bronchial,  but  slightly  blowing. 


54  PULMONARY  DISEASES. 

In  listening  to  the  respiration  of  muscular  subjects,  a  contin- 
uous, low-pitched,  superficial,  rumbling  murmur  is  heard  where 
the  muscles  are  thickest,  which  is  due  to  the  contraction  of 
muscular  fibre.  In  rare  cases  this  is  so  marked  as  closely  to 
resemble  the  vesicular  murmur. 

The  normal  vesicular  murmur  is  modified  in  different  regions 
of  the  chest,  by  the  size  of  the  bronchial  tubes,  and  more  or 
less  by  the  thickness  of  the  chest  walls,  and  by  the  position  of 
other  organs.  It  is  heard  in  perfection  in  the  left  infra-clavic- 
ular region.  On  the  right  side,  the  sound  is  more  intense,  and 
the  expiratory  sound  is  generally  slightly  prolonged ;  there 
may  be  a  very  slight  interval  between' the  inspiratory  and  the 
expiratory  murmurs,  and  the  quality  of  both  is  usually  slightly 
tubular.  This  disparity  is  doubtless  due  to  the  direction  and 
size  of  the  right  bronchus  as  compared  with  the  left. 

Over  the  upper  portion  of  the  sternum  and  the  inner  third 
of  the  infra-clavicular  regions,  the  vesicular  sounds  are  altered 
by  the  proximity  of  the  trachea  and  of  the  large  bronchial 
tubes,  being  somewhat  tubular  or  broncho-vesicular  in  quality. 

In  the  inter-scapular  space,  owing  to  the  thickness  of  the 
chest-walls,  the  vesicular  sounds  are  less  distinctly  heard  ; 
owing  to  the  presence  of  the  main  bronchi  they  are  more  tubu- 
lar in  character,  so  that,  in  this  position  also,  we  find  a  sound 
which  might  properly  be  termed  the  broncho-vesicular  mur- 
mur, but  which  is  usually  called  normal  bronchial  breathing. 

In  the  scapular  regions,  the  thickness  of  the  chest-walls 
renders  the  vesicular  sound  indistinct. 

In  children,  the  vesicular  murmur  is  much  more  intense 
than  in  adults.  Over  the  upper  portion  of  the  chest  it  is  usually 
much  more  intense  in  the  female  than  .in  the  male.  In  the 
aged,  it  frequently  loses  something  of  its  soft  quality,  and  be- 
comes slightly  more  tubular,  and  is  altered  in  its  rhythm,  the 
expiratory  sound  being  occasionally  preceded  by  a  short  period 
of  silence,  and  having  a  duration  nearly  or  quite  equal  to  the 
inspiratory  murmur.  This  change  in  the  aged  seems  due  to 
partial  atrophy  of  lung  tissue  and  to  changes  in  the  elasticity 
of  the  chest-walls. 

In  extreme  anaemia,  the  vesicular  murmur  is  intensified  over 
the  entire  chest. 

LARYNGEAL  AND  TRACHEAL  RESPIRATION. — Over  the  larynx 


AUSCULTATION. 


55 


and  the  trachea  the  respiratory  murmur  is  practically  the  same  ; 
it  is  known  as  laryngeal  and  tracheal  respiration.  This  differs 
from  the  vesicular  respiration  in  its  intensity,  pitch,  quality, 
duration  and  rhythm.  The  inspiratory  sound  in  these  varieties 
of  respiration  is  much  more  intense  than  the  vesicular  mur- 
mur, its  pitch  is  higher,  its  quality  tubular,  and  there  is  a 
marked  interval  between  it  and  the  expiratory  sound. 

The  expiratory  sound  is  generally  found  to  be  more  intense 
than  the  inspiratory,  and  even  higher  in  pitch.  It  has  the  same 
tubular  quality,  and  about  the  same  duration.  To  sum  up  these 
points  of  distinction,  we  find  that  these  varieties  of  respiration 
differ  from  the  vesicular  in  being  more  intense,  higher  pitched, 
and  tubular  in  quality  ;  in  having  an  interval  between  the  two 
portions  of  the  act,  and  in  the  expiratory  sound  being  of  equal 
length  with  the  inspiratory,  or  of  greater  duration. 

BRONCHIAL  RESPIRATION,  or,  perhaps  more  properly,  bron- 
cho-vesicular respiration,  is  next  in  importance  to  the  vesicular. 
It  may  always  be  found  in  the  healthy  chest,  but  it  is  only 
heard  over  a  limited  area,  immediately  over  and  surrounding 
the  large  bronchial  tubes.  I  think  the  latter  term  more  appro- 
priate, as  this  combines  both  the  bronchial  and  the  vesicular 
varieties.  True  bronchial  breathing  is  the  same  as  tracheal, 
excepting  that  it  is  usually  less  intense.  It  is  the  sound  which  is 
obtained  in  pulmonary  diseases  where  the  air-vesicles  are  com- 
pletely filled  by  inflammatory  lymph  or  other  products.  Bron- 
cho-vesicular respiration  holds  a  place  midway  between  bron- 
chial and  vesicular,  and  is  the  sound  which  is  obtained  when 
only  a  portion  of  the  air-vesicles  are  occluded. 

The  sound  heard  over  the  main  bronchial  tubes  in  the  healthy 
chest  is  more  intense  than  the  vesicular  murmur  and  its  pitch  is 
higher ;  its  quality  is  a  combination  of  the  vesicular  and  tubular, 
and  a  slight  interval  may  be  noticed  between  inspiration  and 
expiration.  The  expiratory  sound  is  of  nearly  equal  duration 
with  the  inspiratory. 

You  will  at  once  perceive  the  necessity,  of  being  able  to  rec- 
ognize these  normal  sounds,  and  of  knowing  the  localities  in 
which  they  are  obtained  ;  for  some  of  these  when  heard  in  ab- 
normal positions,  become  the  signs  of  grave  diseases. 


LECTURE  VI. 
AUSCULTATION    IN    DISEASE. 

The  auscultatory  sounds  are  altered  by  disease,  principally 
in  their  intensity,  rhythm  and  quality. 

The  intensity  may  be  increased,  giving  rise  to  what  is  known 
as  exaggerated,  compensatory  or  supplementary  respiration. 
It  may  be  diminished,  and  is  then  called  feeble  respiration ;  or 
the  sounds  may  be  entirely  suppressed.  The  rhythm  of  the 
murmur  may  be  interrupted.  It  is  then  termed,  jerking,  wavy, 
or  cog-wheel  respiration ;  and  the  interval  between  the  two  por- 
tions of  the  act  may  be  lengthened,  or  the  expiratory  sound 
may  be  prolonged. 

The  quality  of  the  sound  may  be  rude,  which  is  termed  bron- 
cho-vesicular ;  it  may  be  bronchial ;  it  may  be  cavernous  or 
amphoric. 

EXAGGERATED  RESPIRATION  differs  from  the  normal  respi- 
ratory murmur  in  intensity  and  in  duration,  both  the  inspiratory 
and  the  expiratory  sounds  being  intensified  and  somewhat  pro- 
longed. It  is  produced  in  lung  tissue  which  is  performing  more 
than  its  ordinary  function.  When  obtained  over  the  chest  of 
an  adult,  it  closely  resembles  the  natural  sound  in  a  child ; 
therefore,  it  has  been  termed  puerile  respiration.  It  is  also 
termed  supplementary  or  compensatory  respiration.  Like 
exaggerated  percussion 'resonance,  it  may  be  said  to  indicate 
the  highest  degree  of  health  in  the  organs  where  it  is  produced  ; 
but  it  also  points  to  disease  of  some  other  portion  of  the  respi- 
ratory tract,  and  is  therefore  a  valuable  negative  sign.  The 
causes  of  this  sign  are  found  in  any  of  those  conditions  which 
may  interfere  with  the  entrance  of  air  into  a  portion  of  the 
respiratory  organs,  and  thus  occasion  more  activity  in  the 
remainder.  Thus,  when  the  lung  is  partially  consolidated  or 
collapsed,  we  get  exaggerated  respiration  well  marked  in  the 
sound  portion  of  the  affected  organ,  and  more  or  less  also  on 
the  sound  side. 


AUSCULTATION.  57 

When  the  lung  is  compressed  by  air  or  fluid  in  the  pleural  sac, 
the  respiration  of  the  opposite  side  is  exaggerated. 

Diminution  of  the  calibre  of  a  bronchial  tube,  as  by  compression 
from  aneurismal  tumors  or  enlarged  glands,  thickening  of  its 
mucous  membrane  or  contraction  of  its  wall,  and  obstruction 
from  the  presence  of  fluid  or  other  foreign  substance  in  suffi- 
cient quantity  to  interfere  materially  with  the  transmission  of 
air,  will  give  rise  to  this  sign  in  the  portions  of  the  lung  not 
thus  obstructed. 

(Edema  of  the  lungs  may  cause  exaggerated  respiration  over 
their  apices.  In  hemiplegia,  the  respiratory  muscles  on  one  side 
act  imperfectly,  and  cause  exaggerated  respiration  on  the  other 
side. 

FEEBLE  RESPIRATION  differs  from  the  normal  vesicular  mur- 
mur in  being  less  intense,  and  shorter  in  duration.  The  inspira- 
tory  part  of  the  sound  is  most  affected.  The  sign  may  be  occa- 
sioned by  anything  which  interferes  with  the  perfect  transmis- 
sion of  sounds  to  the  surface,  as  thick  chest-walls,  whether  due 
to  muscular  or  to  adipose  tissue ;  it  is  also  caused  by  small 
quantities  of  air,  fluid,  or  inflammatory  lymph  in  the  pleural  sac. 

It  may  result  from  loss  of  elasticity  of  the  lung  tissue  in  con- 
sequence of  dilatation  of  the  air-vesicles,  as  in  pulmonary 
emphysema,  or  from  tubercular  or  inflammatory  consolidation  of 
the  lung ;  also  from  deficient  action  of  the  respiratory  muscles, 
occurring  in  cases  of  paralysis  ;  or  it  may  exist  in  diseases  of  the 
abdominal  or  thoracic  organs  which  give  rise  to  pain,  and  cause 
the  patient  to  restrain  the  muscular  movement. 

Collections  of  fluid  or  gas  in  the  pleural  cavity,  tumors  in  the 
chest,  or  in  the  abdomen— as  a  pregnant  uterus — may  interfere 
with  the  function  of  the  lung,  and  prevent  the  descent  of  the 
diaphragm  by  mechanical  pressure,  thus  causing  feeble  respira- 
tion. 

Obstructions  of  the  larynx,  trachea,  or  bronchi  have  a  similar 
effect  on  the  vesicular  murmur.  This  may  be  caused  by  col- 
lections of  mucus,  pus,  blood  or  other  fluid ;  by  thickening  of 
the  mucous  membrane ;  by  the  pressure  of  a  tumor  on  a  bron- 
chial tube,  or  by  contraction  of  its  walls.  It  may  also  be  due 
to  foreign  bodies  in  the  air-passages  ;  or  to  obstructions  at  the 
glottis,  as  for  example,  oedema,  spasm,  croupous  or  diphtheritic 
membranes,  neoplasms  and  the  like.  More  rarely  it  results 


58  PULMONARY   DISEASES. 

from  paralysis  of  the  dilators  of  the  glottis.  Bronchitis  of  the 
smaller  tubes  causes  feeble  respiration.  The  vesicular  murmur 
is  also  diminished  in  spasmodic  contraction  of  the  muscular 
fibres  of  the  bronchial  tubes,  as  in  asthma. 

When  this  diminished  murmur  is  found  in  the  upper  part  of 
one  lung  it  often  indicates  phthisis ;  if  found  over  the  lower 
part  of  the  lung,  it  is  very  often  an  indication  of  pneumonia  ; 
found  over  the  lower  portion  of  both  lungs,  it  may  be  indica- 
tive of  oedema. 

SUPPRESSED  RESPIRATION  is  produced  by  the  same  causes 
which,  occurring  in  a  less  degree,  give  rise  to  feeble  respiration. 
This  sign  is  often  observed  over  the  diseased  portion  of  a  lung, 
the  remainder  of  which  yields  the  exaggerated  respiratory 
murmur.  It  results  from  perfect  occlusion  of  the  air-passages  by 
fluid  or  foreign  bodies  within  them,  or  by  pressure  from  with- 
out, and  from  mechanical  interference  with  the  expansion  of 
the  lung,  as  m  pnetimothorax  and  in  hydrothorax. 

INTERRUPTED  RESPIRATION,  also  known  as  cog-wheel  respira- 
tion.— In  this  variety  of  respiration,  either  or  both  parts  of  the 
respiratory  act  may  be  broken  into  two  or  more  parts,  the  sound 
being  suddenly  interrupted,  to  return  again,  and  perhaps  again 
and  again,  before  a  single  respiration  is  complete.  The  inter- 
ruption takes  place  most  frequently  with  inspiration.  The  sign 
is  found  under  a  variety  of  circumstances,  and  not  only  in  several 
diseases,  but  also  in  health,  so  that  it  is  not  of  much  importance, 
though  it  will  sometimes  help  to  confirm  a  diagnosis  based  on 
other  evidence.  It  is  sometimes  noticed  over  the  whole  chest, 
and  at  other  times  it  is  confined  to  a  limited  space. 

When  occurring  in  health,  it  is  often"  heard  over  the  whole 
chest ;  but  when  resulting  from  pulmonary  disease,  it  is  more  apt 
to  be  localized.  In  the  incipiency  of  phthisis,  this  sign  is  fre- 
quently obtained  directly  over  the  diseased  lung,  especially 
when  the  lesions  are  situated  in  the  left  apex. 

This  sign  may  be  produced  by  any  disease  which  renders 
respiration  painful,  as  intercostal  neuralgia, pleurisy,  and  rheuma- 
tism of  the  thoracic-walls.  It  also  occurs  in  nervous  persons 
who  are  agitated  by  the  examination,  and  is  very  apt  to  be 
found  in  hysterical  patients.  When  due  to  nervousness  or  to 
pain,  the  sign  will  be  found  over  the  entire  lung,  or  over  both 
lungs. 


AUSCULTATION.  59 

As  an  indication  of  disease,  interrupted  respiration  is  a  sign 
of  very  little  value,  excepting  in  the  early  stage  of  phthisis.* 

INTERVAL  PROLONGED. — -The  interval  between  inspiration 
and  expiration  may  be  prolonged  by  shortening  of  the  inspira- 
tory  murmur,  or  by  a  delay  in  the  commencement  of  the  expi- 
ratory murmur. 

Shortened  Inspiration. — The  inspiratory  sound  ceases  before  the 
act  is  complete,  and  is  correspondingly  shortened  in  partial  con- 
solidation of  the  lung  due  to  inflammatory  or  tubercular  deposits. 
It  is  deferred  in  its  commencement  after  the  inspiratory  act  be- 
gins, and  thus  is  shortened  where  the  air-vesicles  are  dilated. 

Deferred  Expiration. — The  expiratory  sound  is  delayed  when 
the  air-vesicles  are  distended  by  pulmonary  emphysema. 

PROLONGED  EXPIRATION. — This  results  from  a  loss  of  elas- 
ticity of  the  lungs,  either  by  consolidation  or  by  detention. 

When  due  to  consolidation,  a  prolonged  expiratory  murmur 
is  usually  more  intense  than  the  normal  sound.  It  is  high- 
pitched  and  more  or  less  tubular  in  quality,  and  usually 
possesses  so  much  of  the  bronchial  element  as  to  be  termed 
broncho-vesicular.  The  prolonged  expiratory  murmur  which 
is  sometimes  found  in  healthy  chests  possesses  the  same  pitch 
and  quality  as  the  normal  vesicular  sound,  which  enables  us  to 
distinguish  it  from  the  prolonged  expiration  of  consolidation, 
in  which  the  pitch  is  always  high,  and  the  quality  somewhat 
tubular.  We  must  not  forget  that  in  health  the  vesicular  mur- 
mur over  the  right  apex  is  more  or  less  tubular,  and  high  in 
pitch,  and  that  the  expiratory  sound  is  prolonged,  as  compared 
with  the  left  side.  Therefore,  in  this  position,  the  sign  cannot 
always  be  considered  as  indicative  of  disease,  unless  it  be  taken 
in  connection  with  other  signs. 

When  obtained  on  the  left  side,  abnormally  prolonged  ex- 
piration is  nearly  always  due  to  phthisis  or  to  emphysema. 
The  difference  in  the  two  instances  is,  that  in  consumption  the 
expiratory  sound  is  high-pitched  and  more  or  less  tubular  in 
quality  ;  while  in  emphysema,  it  is  usually  even  more  prolonged 
—it  may  be  two  or  three  times  as  long  as  the  inspiratory  mur- 
mur— and  it  has  a  low  pitch,  it  is  not  tubular  but  rather  vesicular 

*  In  this  condition  the  immediate  cause  of  this  sign  seems  to  be  forcible  contrac- 
tion of  the  heart,  whereby  an  abnormal  amount  of  blood  is  forced  into  the  pulmonary 
circuit,  thereby  causing  some  narrowing  of  the  calibre  of  the  bronchial  tubes. 


60  PULMONARY  DISEASES. 

in  quality,  and  it  is  apt  to  be  considerably  less  intense  than  the 
inspiratory  sound. 

Whenever  the  prolonged  expiratory  murmur  is  high  in  pitch 
and  tubular  in  quality,  it  indicates  consolidation  of  the  pulmo- 
nary parenchyma.  But  the  normal  disparity  between  the  two 
infra-clavicular  regions  must  not  be  forgotten,  for  this  character 
of  respiration  on  the  right  side  is  not  necessarily  indicative  of  dis- 
ease unless  the  inspiratory  murmur,  and  other  signs  be  altered. 

Occasionally,  prolonged  expiration  may  be  caused  by  interference  with  the  free  exit 
of  air  from  the  lungs,  as  obstruction  in  the  larynx  or  in  the  bronchial  tubes.  In  these 
cases,  it  is  usually  associated  with  a  deferred  inspiratory  murmur,  in  which  the  sound 
does  not  begin  with  the  inspiratory  act. 

Exceptional. — Prolonged  expiration  having  the  pitch  and  quality  of  the  healthy  mur- 
mur is  obtained  with  cavernous  respiration  in  rare  cases.  In  such  instances  its  signifi- 
cance is  ascertained  by  the  character  of  the  inspiratory  sound  and  by  other  signs. 

RUDE  RESPIRATION,  Broncho-vesicular  or  Harsh  Respiration. 
— This  closely  resembles  the  sound  which  can  be  obtained  by 
listening  directly  over  the  bronchial  tubes  in  a  healthy  chest. 

The  respiratory  sound  is  raised  in  pitch  in  proportion  as  the 
tubular  supplants  its  vesicular  quality.  The  expiratory  sound 
is  always  higher  in  pitch  than  the  inspiratory,  its  quality  is 
more  or  less  tubular,  and  it  is  prolonged.  The  extent  of  the 
alteration  in  pitch  and  in  duration  is  in  proportion  to  the  pre- 
ponderance of  the  tubular  over  the  vesicular  quality. 

Disease  may  furnish  all  degrees  of  broncho-vesicular  respira- 
tion according  to  the  amount  of  consolidation,  from  the  normal 
vesicular  murmur  to  perfect  bronchial  breathing. 

This  sign  is  due  to  the  better  transmission  of  the  vibrations 
from  the  larynx,  trachea,  and  bronchial  tubes  to  the  surface  of 
the  chest,  in  consequence  of  the  consolidation  of  the  air-vesicles, 
which  makes  the  parenchyma  a  better  conductor  of  sound- 
waves, and  renders  the  bronchial  tubes  more  rigid,  so  that  they 
transmit  these  waves  from  the  upper  air-passages  with  less  re- 
sistance. 

The  sign  is  obtained  in  incipient  phthisis  over  the  upper  part 
of  the  lung,  and  in  pneumonia,  usually  over  the  lower  lobe.  It 
is  also  heard  in  some  cases  of  pulmonary  apoplexy,  and  over  a 
lung  which  has  been  pressed  upon  for  a  considerable  time  by 
fluid  or  air  in  the  pleural  sac ;  or  over  a  lung  a  portion  of  whose 
air-vesicles  have  collapsed  from  any  cause. 

It  is  most  valuable  as  a  sign  of  incipient  phthisis. 


AUSCULTATION.  6r 

Exceptional. — In  cases  where  broncho-vesicular  respiration  occurs,  either  the  inspi- 
ratory  or  expiratory  murmur  may  be  absent;  then,  as  in  similar  instances  of  bronchial 
respiration,  its  detection  will  depend  on  the  pitch  and  quality  of  the  sounds  which  are 
present,  and  upon  concomitant  signs. 

BRONCHIAL  RESPIRATION  is  one  of  the  most  important  varie- 
ties of  the  healthy  sounds,  which  may  sometimes  be  indicative 
of  disease.  Its  quality  and  its  other  elements  are  almost  ex- 
actly the  same  as  those  of  normal  tracheal  respiration.  The 
intensity  of  this  sound  is  usually  greater  by  far  than  that  of  the 
vesicular  murmur,  but  sometimes  it  is  very  feeble ;  the  pitch 
is  high,  the  quality  tubular,  and  the  duration  both  of  inspira- 
tion and  expiration  is  prolonged  and  the  two  are  of  about  equal 
length.  There  is  an  appreciable  interval  between  the  inspira- 
tory  and  expiratory  sounds. 

Exceptional. — In  this  variety  of  respiration,  either  portion  of  the  respiratory  murmur 
may  sometimes  be  absent. 

Laennec  taught  that  the  bronchial  sound  was  always  pro- 
duced in  a  healthy  chest,  but  that  it  was  not  usually  heard  be- 
cause of  the  intervention  of  air  vesicles  between  the  tubes  and 
the  chest-walls.  When  obtained  in  disease,  he  considered  the 
sign  due  simply  to  the  better  transmission  of  the  sounds  to  the 
surface.  Skoda  believed  that  consolidation  of  the  air-vesicles 
surrounding  the  bronchus  was  necessary  for  the  production  of 
the  perfect  sign.  Whichever  of  these  views  is  correct,  or 
whether  both  are  in  part  true,  matters  little  to  us,  so  long  as 
we  know  that  the  sign  always  indicates  consolidation  of  lung 
tissue  (Fig.  23,  page  121).  The  tubular  sounds  in  this  variety 
of  the  respiratory  murmur  are  transmitted  for  a  considerable 
distance  beyond  the  consolidated  lung,  which  accounts  for  the 
fact  that  the  bronchial  and  the  vesicular  elements  are  frequently 
combined  in  the  regions  immediately  surrounding  that  which 
yields  simply  bronchial  respiration.  The  greater  intensity  of 
the  expiratory  sound  in  bronchial  respiration  accounts  for  the 
fact  that  occasionally  we  obtain  a  vesicular  inspiratory,  and  a 
bronchial  expiratory  sound ;  as  the  intensity  of  the  bronchial 
sound  drowns  the  vesicular,  in  expiration. 

Bronchial  respiration  is  found  in  greatest  perfection,  in  pneu- 
monia, over  the  consolidated  lung.  It  is  obtained  also  in  some 
cases  of  phthisis  ;  but  in  this  affection  we  are  more  apt  to  hear 
broncho-vesicular  respiration. 


62  PULMONARY   DISEASES. 

Exceptional. — In  rare  cases  cancer  of  the  lung  yields  bronchial  breathing. 
Pulmonary  apoplexy  sometimes  causes  the  sign;  and  it  is  heard  over  the  entire  chest» 
though  more  distant  than  in  consolidation,  in  a  few  cases  of  pleurisy  with  extensive 
effusion. 

CAVERNOUS  RESPIRATION  has  been  likened  to  both  bronchial 
and  vesicular.  We  are  told  by  one  author  that  it  closely 
resembles  the  former,  and  by  another  that  great  care  is  neces- 
sary to  distinguish  it  from  the  latter.  This  discrepancy  is 
doubtless  due  to  confusion  in  the  application  of  the  term  to 
different  signs.  Prof.  Flint  has  made  the  distinction  clear  by 
introducing  another  term,  viz.,  broncho-cavernous,  to  designate 
those  sounds  which,  although  conveying  the  idea  of  a  cavity 
to  the  listener,  do  not  correspond  with  true  cavernous  respi- 
ration, which  latter  does  not  resemble  bronchial  breathing.  The 
intensity  of  cavernous  respiration  is  usually  feeble,  so  that 
unless  searched  for  carefully,  it  will  be  overlooked.  The  pitch 
is  low ;  and  the  quality,  instead  of  being  vesicular  or  tubular,  is 
soft  and  blowing  or  puffing.  The  expiratory  portion  of  the  sound 
is  prolonged  to  about  the  same  length  as  the  inspiratory,  and  is 
even  lower  in  pitch  than  the  latter.  The  failure  of  some  diag- 
nosticians to  appreciate  the  quality  of  this  sound  has  caused 
them  to  deny  its  existence.  I  am  satisfied  that  the  true  cavern- 
ous murmur,  as  just  described,  can  be  heard  occasionally,  but 
1  think  it  a  very  rare  sign.  This  sign  is  produced  in  empty 
pulmonary  cavities,  the  walls  of  which  are  so  flaccid  that  they 
expand  readily  in  inspiration  and  collapse  in  expiration  (Fig. 
16).  It  is  a  sign,  therefore,  of  any  of  those  diseases  which  might 
cause  such  a  cavity,  viz.,  consumption,  pulmonary  abscess,  or 
gangrene  of  the  lung. 

Broncho-cavernous  respiration  is  made  up  of  both  the  bron- 
chial and  the  cavernous  sounds.  It  is  usually  described  as 
cavernous,  but  it  is  higher  in  pitch  and  more  tubular  in  quality 
than  the  latter. 

This  sound  occupies  a  position  midway  between  bronchial 
and  cavernous.  Its  quality  is  not  sufficiently  tubular  to  be 
called  bronchial,  nor  yet  sufficiently  soft  and  puffing  to  be 
termed  cavernous.  It  is  produced  in  pulmonary  cavities,  sur- 
rounded by  lung  tissue  more  or  less  consolidated  ;  the  tubular 
element  being  dependent  upon  the  amount  of  consolidation. 
Sometimes  the  first  part  of  the  inspiratory  murmur  may  be 


AUSCULTATION.  63 

tubular  in  quality  and  the  last  part  cavernous ;  and  again  we 
may  obtain  cavernous  inspiration  with  bronchial  expiration, 
due  to  the  presence  of  consolidated  lung  tissue  near  the  cavity. 
In  the  latter  case,  the  intense  expiratory  bronchial  murmur 
doubtless  drowns  the  cavernous  sound,  which  was  heard  with 
the  feebler  inspiratory  murmur. 

Broncho-cavernous  respiration  is  the  characteristic  sign  of 
the  latter  stages  of  consumption,  but  is  also  produced  in  the 
cavities  due  to  abscess  or  to  gangrene. 


FIG.  16. — Phthisis. 

AMPHORIC  RESPIRATION  is  a  sound  resembling  that  produced 
by  blowing  into  the  mouth  of  an  empty  bottle,  hence  the  name. 
It  is  of  a  metallic  musical  quality,  and  may  be  heard  during 
either  inspiration  or  expiration,  or  during  both  portions  of  the 
respiratory  act,,  but  it  is  generally  most  marked  in  expiration. 
The  expiratory  sound  is  lower  in  pitch  than  in  bronchial 
breathing.  In  this  connection  I  wish  to  call  your  attention  to 
the  necessity  of  studying  the  pitch  of  the  respiratory  sounds, 
for  in  some  instances  there  is  absolutely  no  other  means  of  dis- 
tinguishing between  the  sounds  transmitted  from  the  bronchial 
tubes  in  consolidated  lungs  and  those  heard  over  pulmonary 


64  PULMONARY   DISEASES. 

cavities.  The  distinction  in  these  cases  is  easy  if  we  remember 
that  the  expiratory  sound  in  the  former  instance  is  always 
high  in  pitch,  and  that  its  pitch  is  low  in  the  latter  case. 

Amphoric  respiration  occurs  under  the  same  conditions  as 
amphoric  resonance,  and  is  frequently  found  in  connection  with 
cracked-pot  resonance.  It  is  due  to  the  passage  of  air,  in  and 
out,  through  an  opening  from  a  bronchus  into  a  large  pulmonary 
cavity  or  into  the  pleural  sac  (Fig.  22,  page  98).  The  sign  is 
obtained  most  perfectly  in  pneumoihorax  or  in  pneumo-hydro- 
thorax.  In  the  latter  it  disappears  and  returns  again,  as  the 
quantity  of  fluid  rises  so  as  to  cover  the  opening  or  falls  below 
it.  This  sign  is  also  heard  in  phthisis  when  the  pulmonary 
cavity  is  large,  and  its  walls  are  firm,  so  that  they  will  not 
collapse  in  expiration. 

Cavities  may  exist  within  the  lungs  without  yielding  either 
of  the  varieties  of  respiration,  which  may  be  caused  by  a 
vomica ;  for  example,  if  a  cavity  be  filled  with  fluid,  or  if  the 
fluid  in  the  cavity  rise  above  the  orifice  of  the  bronchial  tube, 
none  of  these  sounds  will  be  heard  (Fig.  16,  page  63) ;  but  if  the 
patient's  position  be  changed  or  the  amount  of  fluid  decreased 
by  coughing,  the  signs  return. 


LECTURE  VII. 
ADVENTITIOUS    SOUNDS. 

The  auscultatory  sounds,  which  we  have  thus  far  been  study- 
ing, are  such  as  may  be  obtained,  in  more  or  less  perfection, 
over  the  healthy  chest.  I  wish  now  to  direct  your  attention  to 
the  accidental  or  adventitious  sounds  which  occur  only  in  dis- 
ease. These  may  accompany  normal  sounds,  or  take  their 
place,  and  will  vary  according  to  their  origin.  Those  pro- 
duced within  the  lungs  are  called  rales,  or  ronchi ;  those  upon 
the  pleural  surfaces  are  termed  friction  sounds.  Rales  are  as 
numerous  and  as  different  in  variety  as  the  shades  of  color,  but 
they  may  be  grouped  into  a  few  distinct  classes,  which  are 
generally  capable  of  some  peculiar  interpretation.  All  of  them 
are  either  dry  or  moist ;  therefore  we  take  this  characteristic 
as  the  starting  point  for  a  classification,  and  group  the  differ- 
ent sounds  under  one  of  these  heads,  according  to  peculiarities 
in  their  pitch  and  quality,  as  shown  below. 

j  Sonorous  rales. 
(  Sibilant  rales. 

Rales 

(  Mucous  rales  (large  and  small). 


Ronchi, 


Moist.  •<  Subcrepitant  rales. 


(  Crepitant  rales. 
Rattles. 

Gurgles  large  and  small. 
Mucous  click. 

Rales  may  originate  in  the  larynx,  trachea,  bronchial  tubes, 
air-vesicles,  or  in  any  cavity  connected  with  the  bronchial  tubes. 
They  are  produced  by  various  conditions  which  interfere  with 
the  passage  of  air  through  the  tubes  and  into  the  air-vesicles. 
They  are  sometimes  heard  in  inspiration,  at  other  times  in 
expiration,  and  again  during  both  portions  of  the  respiratory 
act. 

DRY  RALES  are  distinguished  as  sonorous,  or  sibilant,  accord- 
5 


(£  PULMONARY   DISEASES. 

ing  to  their  pitch,  which  depends  on  the  size  of  the  bronchial 
tube  in  which  they  are  produced. 

SONOROUS  RALES  are  usually  musical,  or  snoring,  resembling 
the  sound  produced  by  blowing  through  a  tube;  they  are 
sometimes  cooing,  sighing,  or  moaning  in  character.  They 
may  be  heard  both  during  inspiration  and  expiration,  but  are 
most  frequent  in  expiration.  These  rales  vary  in  intensity, 
from  a  sound  which  can  be  scarcely  recognized,  to  one  which 
may  be  heard  at  a  distance  from  the  chest.  The  pitch  of  these 
rales  is  always  low,  and  the  quality  more  or  less  musical.  They 
are  produced  in  bronchial  tubes  exceeding  one  eighth  of  an 
inch  in  diameter.  They  are  caused  by  the  vibrations  of  viscid 
mucus,  or  by  a  fold  of  mucous  membrane;  or  by  anything 
which  constricts  the  calibre  of  the  tube,  as  pressure  upon  its 
external  surface  from  tumors  of  any  sort,  bands  of  cicatricial 
tissue  resulting  from  former  diseases,  or  contraction  of  the  circu- 
lar muscular  fibres,  causing  a  uniform  narrowing  of  the  tube  (Fig. 
17).  These  sounds  are  not  removed  by  coughing,  unless  caused 
by  tenacious  mucus  adhering  to  the  side  of  the  bronchial  tube. 
Though  in  the  great  majority  of  instances,  after  coughing,  or 
after  deep  inspiration,  an  individual  rale  may  disappear,  other 
rales  will  remain  in  some  portion  of  the  chest.  This  sign  is 
obtained  in  greatest  perfection  in  the  early  stages  of  acute 
bronchitis,  and  in  asthma.  It  is  also  heard  in  some  cases  of 
chronic  bronchitis,  occasionally  in  phthisis,  and  rarely  in  pneumo- 
nia. In  these  latter  instances,  it  is  associated  with  other  adven- 
titious sounds. 

•When  obtained  in  phthisis,  the  dry  rales  are  few  in  number, 
and  are  associated  with  moist  rales. 

In  the  early  stage  of  asthma,  sonorous  rales  may  be  heard 
in  great  numbers  over  the  entire  chest. 

SIBILANT  RALES  occur  both  in  inspiration  and  in  expiration, 

but  are  heard  mostly  in  inspiration.     They  are  not  so  intense 

as  the  sonorous  sounds.     Their  pitch  is  high,  and  in  quality 

iey  vary  almost  as  much  as  sonorous  rales,  being  sometimes 

tlmg,  sometimes  hissing,  and  sometimes  almost  creaking. 

They  are  caused  in  the  smaller  bronchial  tubes  by  the  same 

which  give  rise  to  raies  in  the  larger  bronchi 


They  are  heard  most  frequently  and  abundantly  in  asthma 


ADVENTITIOUS   SOUNDS.  v  6? 

and  in  capillary  bronchitis.     In  ordinary  acute  bronchitis,  these 
rales  will  be  heard,  though  in  limited  numbers. 

They  are  heard  occasionally  in  phthisis,  due  then  to  localized  bronchitis,  or  to  tuber- 
cular deposits.  They  are  sometimes,  though  not  often,  heard  in  pneumonia.  Occa- 
sionally, even  in  healthy  or  apparently  healthy  chests,  we  may  hear  two  or  three  of 
these  fine  sounds  near  the  borders  of  the  lungs. 

% 

Sibilant  rales  may  be  altered,  but  they  are  seldom  removed, 
by  coughing  or  by  forced  inspiration. 

Mucous  RALES  are  also  produced  in  the  bronchial  tubes, 
and  are  large  or  small  according  to  the  tubes  in  which  they 
are  produced.  They  are  caused  by  air  bubbling  through  fluid, 
which  may  be  mucus,  pus,  serum,  or  blood  (Fig.  17).  If  the 


Sonorous  Rules. 

J^fes^—^J^    / 

Subcrepitant  Rules .^?T 


Mucous  Rules.- 

•f  •»  m        JL 

^Sibilant  Rales. 


Crepitant  Rales. 

FIG.  17. — Bronchial  rales,  dry  and  moist,  and  subcrepitant  rales. 

bubble  happen  to  be  in  the  large  bronchus  we  get  a  large, 
coarse,  mucous  rale  ;  if  in  a  smaller  bronchus,  the  rale  is  much 
finer. 

These  rales  are  heard  during  both  inspiration  and  expiration. 
They  vary  greatly  in  intensity.  Sometimes,  like  sonorous  rales, 
they  may  be  heard  at  a  distance  from  the  chest,  while  at  other 
times  they  are  hardly  audible.  The  pitch  of  mucous  rales 
depends  upon  the  condition  of  the  surrounding  lung  tissue. 
In  simple  inflammation  of  the  mucous  membrane  the  rales  are 
low-pitched,  but  when  consolidated  lung  tissue  surrounds  the 
bronchial  tubes,  as  in  pneumonia  and  in  phthisis,  the  pitch  is 
high.  These  sounds  are  obtained  with  greatest  perfection  in 
chronic  bronchitis. 


6g  PULMONARY  DISEASES. 

They  may  be  heard  in  acute  bronchitis  after  the  dry  stage  has 
passed.  They  are  present  in  greater  or  less  degree  in  nearly 
all  cases  of  consumption,  in  the  third  stage  of  pneumonia,  and  in 
pulmonary  oedema.  These  rales  are  numerous  when  hemorrhage 
has  taken  place  into  the  bronchial  tubes  until  coagulation  occurs. 
In  phthisis  they  are  found  over  a  limited  space,  due  sometimes 
to  associated  bronchitis,  at  other*times  to  the  escape  of  fluid 
from  a  cavity  into  the  bronchial  tubes.  These,  unlike  the  dry 
rales,  are  usually  much  affected  by  deep  inspiration,  and  by 
coughing  by  which  they  may  be  considerably  altered  or  en- 
tirely removed. 

SUBCREPITANT  RALES. — These  are  moist  sounds,  which  are 
produced  in  the  very  fine  bronchial  tubes,  probably  in  the 
ultimate  bronchi  and  those  a  size  larger  (Fig.  17,  page  67). 
They  are  caused  by  air  bubbling  through  fluid,  and  may  be 
heard  during  either  portion  of  the  respiratory  act  alone,  or  dur- 
ing both  inspiration  and  expiration,  but  they  are  most  frequently 
heard  with  inspiration.  They  are  of  comparatively  feeble 
intensity,  and  vary  in  pitch  according  to  the  condition  of  the 
surrounding  tissue.  These  sounds  are  distinctly  moist,  and 
crepitating  or  crackling  in  quality. 

These  rales  may  be  heard  most  perfectly  in  capillary  bron- 
chitis and  in  the  third  stage  of  pneumonia.  They  are  often  found 
in  asthma  shortly  after  the  paroxysm.  They  are  present  in 
congestion  of  the  lung,  purulent  bronchitis,  and  pulmonary  cedema, 
and  are  found  over  a  limited  portion  of  the  lung  in  many  cases 
of  phthisis.  They  occur  in  brown  induration  of  the  lungs,  and 
are  heard  after  hemorrhage  into  the  smaller  bronchial  tubes, 
limited  to  the  position  of  the  hemorrhage. 

The  subcrepitant  rale,  due  to  circumscribed  capillary  bron- 
chitis, is  a  sign  of  great  value  in  the  early  diagnosis  of  phthisis, 
in  which  it  may  often  be  found  at  the  apex  of  the  lung  before 
any  other  signs  can  be  detected. 

THE  CREPITANT  RALE  is  largely  like  the  subcrepitant,  but 
differs  from  the  latter  in  two  respects :  viz.,  it  is  not  so  moist  or 
liquid  in  character,  so  that  it  is  sometimes  classed  as  a  dry  rale, 
and  it  is  never  obtained  in  expiration.  Crepitant  rales  are  very 
well  imitated  by  rubbing  together  a  lock  of  hair  close  to  the 
They  were  compared  by  Laennec  to  the  sound  produced 
by  throwing  salt  upon  the  fire. 


ADVENTITIOUS   SOUNDS.  ^ 

These  rales  are  produced  in  the  vesicles,  intercellular  spaces, 
and  ultimate  bronchi  (Fig.  17,  page  67).  There  are  two  theo- 
ries as  to  their  mode  of  production ;  one  is  that  they  are  caused 
by  air  bubbling  through  fluid  within  the  air-vesicle,  in  the 
same  way  that  mucous  rales  are  produced  in  the  bronchial 
tubes ;  the  other,  that  they  are  due  to  the  separation  of  the 
agglutinated  surfaces  of  the  capillary  tubes  or  of  the  air-vesicles. 
Which  of  these  is  true,  or  whether  both  are  in  part  correct, 
has  not  been  decided.  To  me  they  seem  to  be  produced  by 
separation  of  the  sticky  surfaces  of  the  air  vesicles,  and  of  the 
capillary  bronchi.  This  view  is  supported  by  the  fact  that  in 
some  cases  of  pneumonia,  for  instance,  when  associated  with 
inflammatory  rheumatism,  no  crepitant  rale  can  be  obtained  ; 
absence  of  the  rale  in  such  cases  ftiay  be  accounted  for  by 
difference  in  viscidity  of  the  inflammatory  lymph,  for  if  the 
sounds  were  produced  by  air  bubbling  through  fluid  they 
would  occur  regardless  of  the  nature  of  that  fluid. 

Crepitant  rales  are  much  more  numerous  than  the  subcrepi- 
tant.  In  listening  to  subcrepitant  rales  we  seldom  seem  to  hear 
more  than  ten  or  fifteen  at  once ;  whereas  with  the  crepitant 
rale  we  seem  to  hear  a  shower  of  a  hundred  or  more  crackling 
sounds  with  each  inspiration. 

Crepitant  rales  are  obtained  in  perfection  in  the  early  stage  of 
pneumonia,  of  which  they  are  considered  diagnostic.  This  stage 
lasts  for  only  a  few  hours;  consequently,  in  many  cases  of  inflam- 
mation of  the  lung,  we  do  not  hear  crepitant  rales,  as  they  have 
disappeared  before  we  see  the  patient. 

A  few  crepitant  rales  are  sometimes  heard  in  congestion  of 
the  lung,  or  in  pulmonary  oedema ;  and  they  are  frequently 
found  in  phthisis,  in  a  small  zone  beyond  the  consolidated  por- 
tion of  the  lung.  In  this  latter  case  they  seem  to  result  from 
gradual  extension  of  the  pneumonitis,  which  often  precedes 
tubercular  deposit. 

Crepitant  and  subcrepitant  rales  and  friction  sounds  are 
sometimes  so  much  alike  that  it  is  difficult  to  distinguish  be- 
tween them.  If  dry  crepitating  sounds  are  numerous,  and  heard 
only  in  inspiration,  they  are  crepitant  rales;  but  if  dry  crepitating 
sounds  are  few  in  number  and  are  heard  in  expiration  or  in  both 
inspiration  and  expiration,  they  are  likely  to  be  friction  sounds. 
Subcrepitant  rales  are  more  moist,  and  they  are  not  nearly  so 


PULMONARY  DISEASES. 

numerous  as  crepitant  rales,  and  they  are  usually  heard  both  in 
inspiration  and  in  expiration.  The  moist  character,  the  number, 
and  the  time  of  occurrence  of  subcrepitant  rales  will  enable  us 
to  distinguish  them  from  the  crepitant ;  and  their  deeper  seat 
and  their  constancy  will  usually  enable  us  to  distinguish  them 
from  fine  friction  sounds— which  are  still  fewer  in  number- 
even  when  the  latter  are  moist  in  character. 

Crepitant  rales  are  not  much  affected  by  cough  or  forced 
respiration,  when  due  to  pneumonia,  but  in  other  instances, 
two  or  three  full  inspirations  will  frequently  dispel  them. 

Exceptional.— Both  crepitant  and  subcrepitant  rales  are  sometimes  brought  out 
directly  after  coughing,  where  they  were  absent  a  moment  previously.  A  sound  closely 
resembling  the  subcrepitant  or  the  crepitant  rale  may  frequently  be  obtained  over  the 
thin  border  of  the  healthy  lung  ;  ia  these  instances,  only  a  few  of  the  rales  are  heard, 
and  they  disappear  after  three  or  four  forced  inspirations. 

GURGLES  resemble  large  mucous  rales,  but  they  are  generally 
higher  in  pitch  and  possess  a  hollow  metallic  quality.  They 
occur  during  both  portions  of  the  respiratory  act,  but  are 
most  frequent  in  inspiration.  They  are  produced  by  air  bub- 
bling through  fluid  in  cavities  which  communicate  with  the 
bronchial  tubes  (Fig.  16,  page  63).  If  cavities  are  completely 
filled  with  fluid,  or  if  they  are  entirely  empty,  or  if  the  level  of 
the  fluid  does  not  reach  above  the  opening  of  the  bronchial 
tube,  no  gurgles  will  be  produced.  These  sounds  are  large  or 
small,  in  accordance  with  the  size  of  the  cavity  in  which  they 
are  produced. 

This  sign  is  usually  indicative  of  phthisis,  but  it  may  occur  in 
any  of  the  diseases  which  cause  excavations  in  the  lung. 

THE  Mucous  CLICK  resembles  an  isolated  subcrepitant  rale  ; 
it  is  heard  during  inspiration  only.  The  sign  generally  con- 
sists of  a  single  click,  or,  at  most,  of  two  or  three  clicks.  It  is 
a  sharp  crackling,  or  clicking  sound,  which  is  supposed  to 
be  produced  in  the  smaller  bronchial  tubes  by  sudden  separa- 
tion of  their  agglutinated  surfaces  during  inspiration  :  it  is  not 
usually  affected  by  cough.  When  heard  over  the  apex  of  one 
lung,  it  is  a  sign  of  considerable  value  in  the  early  diagnosis  of 
phthisis.  These  sounds  are  sometimes  heard  over  a  considera- 
ble portion  of  the  lung  in  acute  tuberculosis,  in  extensive 
scrofulous  pneumonia,  or  in  the  latter  stages  of  interstitial  or 
catarrhal  pneumonia. 


ADVENTITIOUS   SOUNDS. 


FRICTION  SOUNDS  are  produced  by  the  rubbing  together  of 
the  two  surfaces  of  the  pleura,  which  are  either  dry  from 
diminution  of  their  natural'  secretions,  or  roughened  by  exuda- 
tion of  inflammatory  lymph  (Fig.  18).  These  sounds  are  graz- 
ing, rubbing,  grating,  rasping,  or  creaking  in  character;  they 
are  sometimes  dry,  and  sometimes  moist  They  may  be 
simulated  by  rubbing  the  back  of  the  hand,  while  listening  with 
the  stethoscope  on  its  palm,  or  by  rubbing  the  fingers  on  the 
integument  when  auscultating  the  chest.  They  are  usually 
few  in  number,  and  transitory,  being  heard  for  a  few  respira- 


Friction 


Deficient  respiratory     I 

murmur  and  dulness.  f 


Flatness.     Loss  of  re-  \ 

spiratory  sounds.       ) 


FIG.  18. — Acute  Pleurisy. 

The  upper'part  of  the  lung  is  in  a  normal  condition,  or  the  air-cells  are  slightly  dis- 
tended. The  lower  part  of  the  lung  is  partially  collapsed.  The  upper  surface  of  the 
fluid  is  not  horizontal,  but  it  conforms  itself  more  or  less  perfectly  to  the  natural  out- 
line of  thejung. 

tions,  and  then  disappearing  to  return  again  in  a  few  minutes ; 
they  may  be  heard  just  at  the  end  of  inspiration,  or  at  the 
beginning  of  expiration.  This  is  the  characteristic  sign  of 
pleurisy.  The  grazing  friction  sound  is  only  heard  in  the 
beginning  of  the  inflammation,  and  can  be  detected  most  fre- 
quently in  the  circumscribed  pleurisy  accompanying  phthisis. 
Some  one  of  the  other  varieties,  of  which  the  quality  is  of  no 
importance,  may  be  heard  in  the  first  and  third  stages  of  pleu- 


-2    •  PULMONARY   DISEASES. 

risy.  Care  must  always  be  taken  not  to  mistake  for  this  sign 
the  sounds  produced  by  crackling  of  the  hairs  beneath 
the  instrument,  or  by  rubbing  of  the  stethoscope  the  fingers 
or  the  clothing  on  the  surface,  or  of  the  clothing  or  fingers  on 
the  instrument.  Sounds  closely  resembling  the  friction  mur- 
mur are  often  heard  over  the  false  ribs  in  a  healthy  chest. 
They  seem  to  be  produced  by  slight  movements  of  the  skin 
beneath  the  rim  of  the  stethoscope. 

Creaking  or  crumpling  sounds  are  sometimes  obtained  over 
the  chest,  the  signification  of  which  is  not  fully  understood. 
The  creaking  sounds  are  most  frequently  heard  at  the  lower 
part  of  the  thorax,  and  are  supposed  to  be  due  to  old  pleuritic 
adhesions.  Both  creaking  or  crackling,  and  crumpling  sounds 
are  sometimes  obtained  over  the  upper  portion  of  the  chest. 
The  crumpling  sounds  which  are  heard  in  inspiration  resemble 
those  which  may  be  produced  by  inflating  a  dried  bladder ; 
and  they  are  supposed  to  be  produced  from  similar  causes ; 
that  is,  the  inflation  of  dry  emphysematous  air-cells.  Dr.  R. 
E.  Thompson  considers  these  sounds  indicative  of  syphilitic 
disease  of  the  lungs.  When  confined  to  the  apex  of  the  lung, 
they  are  nearly  always  associated  with  phthisis. 


LECTURE  VIII. 
VOCAL  AND  TUSSIVE  SIGNS. 

VOCAL  SOUNDS. 

Considerable  information  regarding  the  condition  of  the  lungs 
can  be  obtained  by  studying  the  sounds  of  the  voice  as  trans- 
mitted through  the  chest-walls. 

If  we  listen  over  the  healthy  chest,  while  the  person  is  speak- 
ing, an  indistinct,  distant  and  muffled  sound  will  be  heard, 
which  is  termed  normal  vocal  resonance.  It  is  due  to  the  fact 
that  sounds  produced  in  the  larynx  are  transmitted  not  only 
outward  through  the  mouth,  but  also  downward  through  every 
portion  of  the  bronchial  tree.  Vocal  resonance,  like  most  of 
the  other  pulmonary  sounds,  varies  greatly  in  different  healthy 
individuals,  and  in  different  portions  of  the  same  chest.  If  a 
person  has  a  low-pitched  intense  voice,  the  vocal  resonance  will 
be  more  forcible  than  in  those  who  have  high-pitched  or  feeble 
voices. 

In  studying  the  voice-sounds  by  immediate  auscultation,  it  is 
desirable  to  close  the  ear  which  is  not  applied  to  the  chest,  in 
order  to  exclude  sounds  coming  from  the  mouth ;  and  it  is 
better  to  have  the  patient  count,  one,  two,  three,  than  to  ask 
him  questions  and  listen  for  the  answers.  By  the  latter  course, 
the  examiner's  attention  is  distracted  from  the  sounds  within 
the  chest  in  the  attempt  to  catch  the  patient's  reply.  The 
varieties  of  vocal  resonance  which  may  be  heard  in  different 
regions  of  the  normal  chest  are  named  from  the  parts  where 
they  are  produced  ;  thus,  over  the  larynx  and  the  trachea  we 
have  laryngeal  and  tracheal  resonance;  over  the  bronchial 
tubes,  bronchial  resonance ;  and  over  air-vesicles,  the  normal 
vesi-alar,  or  as  it  is  usually  termed,  normal  vocal  resonance. 

L    RYNGOPHONY     AND     TRACHEOPHONY.  —  The     VOCal     rCSO- 

nance  obtained  over  the  larynx  is  called  laryngophony,  and 
that    obtained    over    the    trachea,    tracheophony.      In   these 


PULMONARY   DISEASES. 
74 

varieties,  the  words  are  imperfectly  articulated,  but  the  voice 
is  transmitted  to  the  ear  "with  a  force  and  intensity  almost 
painful."  The  sounds  are  concentrated,  or  in  other  words  seem 
to  be  produced  within  a  small  area  immediately  beneath  the 
stethoscope,  and  they  necessarily  vary  in  pitch  with  the  pitch 
of  the  individual's  voice. 

NORMAL  BRONCHOPHONY.— By  listening  while  the  person  is 
speaking,  over  the  bronchial  tubes,  near  the  border  of  the 
sternum  from  the  first  to  the  third  rib,  or  more  especially 
directly  over  the  main  bronchi  on  a  level  with  the  second  cos- 
tal cartilages  in  front,  or  on  a  level  with  the  fourth  dorsal 
vertebra  in  the  inter-scapular  regions,  we  obtain  normal  bron- 
chophony.  This  occupies  a  position  midway  between  normal 
vocal  resonance  and  laryngophony.  The  sounds  thus  obtained 
are  transmitted  to  the  ear  with  considerable  intensity,  though 
with  much  less  force  than  over  the  larynx ;  and  they  appear  to 
be  produced  immediately  beneath  the  stethoscope,  but  the 
words  are  very  imperfectly  articulated.  Whenever  this  sign 
is  obtained  over  any  other  portion  of  the  chest  it  indicates  con- 
solidation of  the  pulmonary  parenchyma. 

NORMAL  VOCAL  RESONANCE. — Listening  to  the  voice  over 
the  vesicular  portions  of  the  lung  we  obtain  the  normal  vocal 
resonance.  This  is  a  distant,  diffused  sound,  having  no  approach 
to  articulation,  which  seems  to  come  from  the  deeper  portions 
of  the  lung,  as  though  produced  two  or  three  inches  beneath 
the  surface.  As  a  rule,  the  vocal  resonance  is  always  more 
intense  upon  the  right  side  than  upon  the  left,  especially  in  the 
infra-clavicular  regions. 

Exceptional. — In  a  few  instances  over  the  right  apex,  even  in  health,  the  resonance 
very  nearly  approaches  bronchophony.  If  the  sounds  have  this  character  upon  both 
sides,  as  they  have  in  rare  instances,  they  will  be  found  most  intense  upon  the  right 
side,  but  higher  in  pitch  on  the  left  side— a  disparity  due  to  the  difference  in  calibre  of 
the  bronchial  tubes.  The  tubes  upon  the  right  side  being  the  larger,  must  necessarily 
give  the  more  intense  and  lower  pitched  sound. 

The  normal  vocal  resonance  varies  in  pitch  with  the  pitch  of 
the  individual's  voice.  It  is  generally  obtained  over  the  entire 
chest  in  adult  males,  but  only  over  the  upper  part  of  the  chest 
m  women  and  children,  in  whom  it  is  a  sign  of  little  value. 

This  sign  is  modified  by  disease,  principally  in  its  intensity, 
which  may  be  either  diminished  or  increased/ 


VOCAL   AND   TUSSIVE   SIGNS.  •-, 

Diminished.    •{  Vocal  sounds  feeble  or  suppressed. 

[Vocal  sounds  exaggerated. 
|  Resonance  which  is  termed  bronchophony. 
Increased.       •{  segophony. 

pectoriloquy. 

amphoric-voice. 

DIMINISHED  RESONANCE  is  due  to  much  the  same  causes  as 
the  diminished  respiratory  murmur ;  that  is,  separation  of  the 
pulmonary  from  the  costal  pleura  by  air  or  fluid,  as  in  pneumo- 
thorax  or  plastic  effusion.  It  occurs  in  cases  of  extreme 
emphysema,  in  pulmonary  oedema,  in  bronchitis  with  free  secre- 
tion, and  occasionally  when  there  is  extreme  pulmonary  consoli- 
dation. 

The  vocal  sounds  are  mostly  suppressed  over  fluid  in  the 
pleural  sac ;  but  just  above  the  level  of  the  fluid  the  air-cells  are 
partially  collapsed,  so  that  vocal  resonance  is  increased.  For 
an  inch  or  an  inch  and  a  half  below  the  level  of  the  fluid  the 
resonance  is  diminished  in  intensity,  and  a  little  lower  it  is 
entirely  suppressed.  Thus  it  will  be  seen  that  we  are  able  to 
ascertain  the  height  of  the  fluid  by  means  of  the  vocal  reso- 
nance as  well  as  by  percussion. 

This  sign  is  principally  of  value  in  the  diagnosis  of  pleuritic 
effusion,  by  enabling  us  to  distinguish  between  it  and  consoli- 
dation of  the  lower  part  of  the  lung. 

Exceptional. — In  some  cases,  the  vocal  resonance  maybe  heard  all  over  the  pleuritic 
effusion,  though  the  sounds  are  distant  and  more  or  less  muffled. 

INCREASED   VOCAL   RESONANCE. 

EXAGGERATED  VOCAL  RESONANCE  differs  from  the  normal 
voice-sounds  simply  in  its  intensity.  This  sign  denotes  more 
or  less  consolidation  of  the  lung  tissue,  of  a  tubercular  or 
inflammatory  character,  or  due  to  collapse  of  the  air-vesicles. 
It  is  usually  associated  with  broncho-vesicular  respiration. 

It  is  a  sign  of  considerable  importance  in  the  diagnosis  of 
the  early  stage  of  phthisis,  and  in  discriminating  between 
pneumonia  and  pleurisy. 

Exceptional.— In  very  rare  cases,  the  vocal   resonance  is  exaggerated  in  pneumo- 

thorax  and  in  emphysema. 


PULMONARY   DISEASES. 
76 

BRONCHOPHONY  consists  of  more  or  less  intense  vocal  sounds, 
usually  imperfectly  articulated,  which  have  a  peculiar  degree 
of  concentration,  or,  in  other  words,  seem  to  be  produced 
immediately  beneath  the  stethoscope,  instead  of  coming  from 
the  deeper  portions  of  the  lung.  The  intensity  of  this  sign, 
which  may  be  greater  or  less  than  that  of  normal  resonance,  is 
an  unimportant  element  ;  so  also  is  the  distinctness  of  articula- 
tion. Its  recognition  depends  chiefly  on  the  characteristic  con- 

centration. 

The  significance  of  bronchophony  depends  upon  the  region 
where  it  is  obtained.  If  heard  over  the  main  bronchial  tubes, 
it  may  be  simply  a  healthy  sound  ;  but  if  heard  over  vesicular 
portions  of  the  lungs,  it  is  indicative  of  consolidation.  It  is 
usually  associated  with  a  tubular  respiratory  murmur  ;  but  as 
it  occurs  with  a  less  amount  of  consolidation  than  is  necessary 
for  true  bronchial  breathing,  it  may  frequently  be  obtained 
with  broncho-vesicular  respiration. 

Exceptional.  —  Bronchophony  usually  possesses  the  characteristic  concentration  ;  but 
when  the  consolidated  lung  is  separated  from  the  chest-wall  by  fluid,  it  may  sound 
distant. 

This  sign  is  of  special  value  in  the  diagnosis  of  the  second 
stage  of  pneumonia  (Fig.  23,  page  121).  It  is  seldom  obtained 
perfectly  in  phthisis,  because  in  this  disease  consolidation  is 
not  usually  complete. 

Exceptional.  —  It  is  occasionally  obtained  in  carcinoma  of  the  lung,  though  usually 
this  disease  involves  the  whole  tissue,  air-vesicles  and  bronchial  tubes  alike;  or  it 
crowds  the  pulmonary  tissue  before  it,  thus  hindering  the  transmission  of  the  voice. 
But  when  the  air  vesicles  alone  are  filled,  and  the  bronchial  tubes  remain  patent,  as 
occurs  in  rare  cases,  bronchophony  may  be  obtained.  It  is  also  obtained  in 
hemorrhagic  infarctions  which  fill  the  air-vesicles,  but  leave  the  bronchial  tubes  open. 
It  may,  therefore,  be  a  sign  in  pulmonary  apoplexy. 


is  a  variety  of  bronchophony.  It  is  a  tremulous 
sound,  which  has  been  compared  to  the  bleating  of  a  goat; 
hence  the  name.  Like  bronchophony,  it  conveys  to  the  listen- 
ing ear  the  impression  of  having  been  produced  within  a  very 
limited  portion  of  the  lung  ;  unlike  the  latter,  it  seems  to  come 
up  from  a  considerable  depth,  and  to  tremble  about  the  end  of 
the  stethoscope.  When  present,  it  may  be  most  readily  ob- 
tained in  the  inter-scapular  or  axillary  regions.  This  sound  is 
generally  produced  in  consolidated  lung  tissue,  which  is  sepa- 


VOCAL   AND   TUSSIVE   SIGNS.  77 

rated  from  the  chest-wall  by  a  thin  layer  of  fluid.  It  is  a  sign 
of  pleuro-pueumonia  that  is,  pneumonia  and  pleurisy  with 
effusion,  but  even  in  this  disease,  it  is  present  only  a  short 
time.  It  is  a  sign  of  little  value.  ^Egophony  is  most  frequently 
produced  when  the  pleura'  cavity  is  about  one  half  filled  with 
fluid. 

In  ordinary  pleuritic  effusions,  the  lung  just  above  the  sur- 
face of  the  fluid  is  more  or  less  solidified  by  collapse  of  a 
portion  of  the  air-vesicles ;  under  such  circumstances  aegophony 
may  be  produced  providing  the  pleura-pulmonalis  and  the 
pleura-costalis  are  agglutinated  just  above  the  collapsed  lung. 

PECTORILOQUY  differs  from  bronchophony  in  that  the  artic- 
ulated speech  is  more  completely  transmitted.  In  bron- 
chophony the  voice  is  heard,  but  the  words  are  not  distinct.  In 
pectoriloquy  articulation  is  nearly  perfect.  There  are  two 
varieties  of  pectoriloquy :  one  in  which  the  sounds  are  concen- 
trated and  near  the  ear  like  bronchophony,  but  are  heard  over 
a  considerable  portion  of  the  lung;  and  another  in  which  the 
sign  is  confined  to  a  limited  space  and  has  not  the  degree  of 
concentration  found  in  bronchophony.  The  first  of  these, 
which  is  high  in  pitch  and  clanging  or  metallic  in  quality,  is 
frequently  produced  by  simple  consolidation  of  lung  tissue. 
The  second,  which  is  low  in  pitch  and  softer  in  quality,  is  always 
a  trustworthy  sign  of  a  pulmonary  cavity  with  smooth  walls 
and  a  large  opening  into  a  bronchial  tube.  Well  defined  pector- 
iloquy is  not  a  frequent  sign,  but  when  heard,  the  first  variety 
is  a  sign  of  phthisis  or  pneumonia,  and  the  second  is  a  sign  of 
any  of  those  diseases  which  cause  vomicae,  viz.,  phthisis,  pul- 
monary abscess  or  gangrene,  and  bronchiectasis. 

AMPHORIC  VOICE. — The  amphoric  voice  is  hollow  and  more 
or  less  musical  in  character.  The  musical  quality  follows  the 
voice  and  is  termed  the  amphoric  echo.  The  words  are  not 
articulated,  as  in  pectoriloquy.  This  sign  occurs  under  the 
same  conditions  as  amphoric  respiration  and  amphoric  per- 
cussion resonance  ;  that  is,  over  the  pleural  sac  when  containing 
air  and  communicating  freely  with  a  bronchial  tube,  and  over 
very  large  cavities  in  the  lungs. 

Exceptional.—  There  are  good  reasons  for  believing  that,  in  rare  cases,  this  sign,  as 
well  as  amphoric  respiration,  may  be  heard  over  a  layer  of  air  in  the  pleural  cavity 
which  does  not  communicate  with  the  bronchial  tubes. 


PULMONARY   DISEASES. 
7» 

Amphoric  voice  is  a  sign  of  pneumothorax,  in  which  disease 
it  is  associated  with  tympanitic  resonance  over  the  upper  part 
of  the  chest,  and  ordinarily  with  the  succussion  sound.  If 
these  latter  signs  are  absent,  the  amphoric  voice  is  probably  pro- 
duced in  a  phthisical  cavity. 

WHISPERING  VOCAL  RESONANCE. 

Prof.  Austin  Flint  has  described  the  whisper  resonance  with 
considerable  minuteness.  He  considers  the  signs  which  it 
furnishes  of  equal  value  with  those  from  a  loud  voice ;  I  find 
them  of  even  greater  importance.  In  listening  over  the  upper 
portion  of  the  chest,  when  a  person  is  speaking  in  a  sharp 
whisper,  sounds  will  be  heard  of  a  blowing  or  tubular  character, 
very  closely  resembling  the  sound  of  forced  respiration.  This 
is  termed  the  normal  bronchial  whisper.  Its  modifications  by 
disease  are  classified  as  exaggerated  bronchial  whisper,  whis- 
pering bronchophony,  cavernous  whisper,  whispering  pectoril- 
oquy,  and  amphoric  whisper. 

EXAGGERATED  BRONCHIAL  WHISPER  is  more  intense  and 
higher  in  pitch  than  the  normal  sound.  It  is  produced  in  lungs 
which  are  slightly  solidified. 

WHISPERING  BRONCHOPHONY  is  higher  in  pitch  and  more 
intense  and  blowing  than  the  preceding.  It  has  the  same 
characteristic  concentration  and  nearness  to  the  ear  as  bron- 
chophony with  the  loud  voice.  It  may  be  obtained  over  lungs 
so  slightly  solidified  as  to  yield  only  exaggerated  vocal  reso- 
nance when  the  patient  is  speaking  aloud,  therefore  it  can  be 
appreciated  sooner  than  bronchophony  with  the  loud  voice. 
This  fact  renders  whispering  bronchophony  a  most  important 
sign  in  the  early  stage  of  phthisis. 

THE  CAVERNOUS  WHISPER  is  a  low-pitched,  blowing  sound, 
confined  to  a  limited  portion  of  the  'chest.  It  is  produced 
within  pulmonary  cavities  under  the  same  conditions  as  caver- 
nous respiration.  This  sign  is  principally  of  value  in  the  diag- 
nosis of  phthisis. 

WHISPERING  PECTORILOQUY  differs  from  whispering  bron- 
chophony only  in  its  more  perfect  articulation.  When  obtained 
over  a  small  space  only,  this  is  a  sign  of  a  cavity.  It  is  most 
frequently  found  in  phthisis. 

AMPHORIC  WHISPER  occurs  under  the  same  conditions  as  the 


VOCAL   AND   TUSSIVE   SIGNS.  7Q 

amphoric  voice  or  amphoric  resonance  on  percussion;  that  is, 
over  the  pleural  sac  filled  with  air,  or  over  very  large  cavities 
in  the  lung  tissue. 

Aphonic  Pectoriloquy  is  a  term  which  has  been  applied  to  the  voice-sounds  when  the 
patient  is  speaking  in  a  low  tone.  It  has  recently  been  stated  that  these  sounds  can 
be  distinctly  heard,  not  only  over  consolidated  or  collapsed  lung,  but  also  even  when 
the  organ  in  this  condition  is  separated  from  the  thoracic  wall  by  a  collection  of  air  or 
serum;  however,  these  vibrations  are  not  conducted  through  pus.  By  studying  this 
variety  of  vocal  resonance  it  is  claimed  that  we  may  determine  whether  pleural  effusions, 
are  of  a  serous  or  of  a  purulent  character.  I  have  been  able  to  verify  this  statement  in 
a  few  cases. 

METALLIC  TINKLING  is  a  clear,  silvery  tinkling  sound,  like 
that  produced  by  dropping  a  pin  into  a  glass.  It  seems  to  be 
caused  by  the  falling  of  a  drop  of  fluid  from  the  upper  part  of 
a  large  cavity  on  the  surface  of  a  collection  of  fluid  below.  It 
can  sometimes  be  heard  over  one  entire  side,  but  it  is  usually 
most  distinct  on  a  level  with  the  nipple.  When  the  proper 
conditions  are  present  within  the  chest — that  is  a  large  cavity 
containing  air  and  fluid — it  may  be  produced  by  any  agitation, 
such,  for  example,  as  speaking,  coughing,  deep  inspiration,  or 
occasionally  by  the  act  of  swallowing.  The  sign  occurs  most 
frequently  in  the  pleural  cavity,  in  the  disease  known  as  pneu- 
mo-hydrothorax,  but  in  exceptional  instances  it  is  produced  in 
very  large  pulmonary  cavities.  A  sound  very  similar  to  this 
may  sometimes  be  heard  over  the  stomach  when  it  is  distended 
with  gas. 

TUSSIVE   SIGNS. 

The  resonance  of  cough  may  sometimes  be  studied  with 
advantage,  especially  in  children.  The  act  of  coughing  is  often 
of  special  value  in  dislodging  obstructions  in  the  bronchial 
tubes  or  pulmonary  cavities,  and  also  in  causing  a  subsequent 
deep  inspiration  which  will  freely  inflate  the  air-cells,  thus 
bringing  out  signs  which  might  otherwise  be  overlooked.  The 
different  varieties  of  cough  are  classified  as  laryngeal,  bron- 
chial, cavernous,  and  amphoric. 

THE  LARYNGEAL  COUGH  is  usually  more  or  less  hacking  in 
character,  and  often  spasmodic.  It  is  indicative  of  laryngitis. 

BRONCHIAL  COUGH  is  quick,  harsh,  and  brassy.  It  is  accom- 
panied with  a  thrill  or  fremitus,  and  if  severe  is  nearly  always 
attended  with  pain  beneath  the  sternum  or  along  the  inferior 


gg  PULMONARY  DISEASES. 

ribs,  corresponding  to  the  attachment  of  the  diaphragm.     It  is 
generally  indicative  of  bronchitis. 

CAVERNOUS  COUGH  is  produced  under  the  same  circum- 
stances as  cavernous  respiration,  and  is  generally  associated 
with  gurgles.  It  has  a  hollow  quality  and  is  usually  very 

intense. 

AMPHORIC  COUGH  is  more  musical  and  hollow  in  quality, 
it  is  generally  lower  in  pitch,  and  it  seems  to  penetrate  the 
ear  with  less  force  than  the  cavernous.  It  is  heard  over  very 
large  pulmonary  cavities  or  over  the  pleura,  when  filled  with 
air. 

Sometimes  large  pulmonary  cavities  are  traversed  by  trabec- 
ulse  which  yield  a  peculiar  twang  when  the  patient  coughs. 
This  is  of  special  value  as  these  strings  prevent  cavernous  or 
amphoric  voice-sounds. 

Tussive  signs  are  usually,  though  not  always,  transmitted 
through  consolidated  lung,  but  seldom  through  collections  of 
fluid. 

We  may  obtain  considerable  information  about  the  condition 
of  the  lungs  in  children  who  cannot  be  induced  to  speak,  by 
studying  the  cry,  which  is  subject  to  the  same  variations,  and 
arises  from  the  same  cause  as  vocal  resonance  in  adults. 

This  completes  the  description  of  the  signs  which  are 
obtained  by  physical  exploration  of  the  chest  in  diseases  of  the 
lungs  and  pleurae. 


LECTURE  IX. 

DIAGNOSIS  AND  TREATMENT  OF  PULMONARY 

DISEASES. 

With  the  last  lecture,  I  completed  a  description  of  the  phys- 
ical signs  which  are  found  in  the  various  pulmonary  affections ; 
and  now  in  order  to  utilize  them  for  diagnosis,  I  shall  present 
the  groups  of  signs  which  occur  in  individual  diseases,  begin- 
ning with  affections  of  the  pleura. 

PLEURISY   OR   PLEURITIS. 

Pleurisy  consists  of  an  inflammation  of  the  serous  membrane 
covering  the  lungs  and  lining  the  thoracic  walls.  There  are 
three  recognized  varieties  of  this  disease :  the  acute,  the  sub- 
acute,  and  the  chronic  or  suppurative.  The  first  effect  of  in- 
flammation on  this  membrane  is  to  check  its  normal  secretion 
and  cause  drynessof  the  surface.  This  is  soon  followed  by  the 
exudation  of  inflammatory  lymph,  and  with  this  or  immediately 
following  it,  there  is  an  increased  effusion  of  serum  into  the 
pleural  sac.  After  this  has  remained  for  a  variable  length  of 
time,  in  favorable  cases,  it  is  gradually  absorbed.  The  amount 
of  fluid  varies  in  different  varieties  of  the  disease.  In  acute  pleu- 
risy, it  is  not  usually  great,  seldom  occupying  more  than  one 
third,  or  at  most  one  half  of  the  pleural  sac,  though  in  a  few  in- 
stances it  may  be  sufficient  to  fill  the  cavity.  In  subacute  pleu- 
risy, the  quantity  of  fluid  is  greater,  and  is  often  sufficient  to  fill 
the  pleural  cavity,  and  cause  great  distention  of  the  side.  In 
chronic  pleurisy,  or  empyema,  the  amount  of  fluid  is  seldom 
greater  than  in  acute  pleurisy. 

For  the  sake  of  convenience  of  description,  pleurisy  has  been 
divided  into  three  or  four  stages.  By  some  authors,  it  is  divided 
into,  first,  a  dry  stage ;  second,  a  plastic  stage ;  third,  a  stage 
of  effusion ;  and  fourth,  a  stage  of  absorption.  I  prefer  the 
division  into  three  stages  analogous  to  the  three  stages  of  pneu- 
6 


g2  PULMONARY  DISEASES. 

monia.    The  first  of  these  we  will  call  the  dry  stage  ;  the  second, 
the  stage  of  effusion ;  the  third,  the  stage  of  absorption. 

SYMPTOMS. 

The  usual  symptoms  of  this  disease  are,  a  sharp  cutting  pain 
in  the  side,  which  is  aggravated  by  movements  of  the  body 
and  by  respiration ;  rapid  and  incomplete  inspiration ;  a  short 
dry  cough  and  a  hard,  rapid  pulse. 

SIGNS. 

The  most  important  signs  of  pleurisy  are  short  and  catching 
respiration,  friction  fremitus,  and  friction  sounds  heard  on 
auscultation.  There  is  loss  of  vocal  fremitus  and  the  respira- 
tory murmur,  with  flatness  over  the  collection  of  fluid,  after 
effusion  has  taken  place.  The  upper  line  of  flatness  changes 
with  the  changes  in  the  position  of  the  patient  (Fig.  18,  page 

70- 

Signs  of  the  First  Stage. 

In  the  first  stage,  we  have  in  the  beginning  simply  dryness  of 
the  pleura,  and  shortly  afterward  an  exudation  of  inflammatory 
lymph. 

INSPECTION. — By  inspection,  we  observe  jerking  or  inter- 
rupted and  incomplete  respiration,  with  diminution  of  the  expan- 
sive movements  of  the  affected  side.  This  catching  respiration 
results  from  the  patient's  efforts  to  limit  the  inspiratory  move- 
ment, in  order  to  prevent  pain.  If  the  patient  is  sitting  or  in  a 
semi-recumbent  position,  his  body  will  be  inclined  toward  the 
affected  side.  If  recumbent,  he  is  likely  to  be  lying  on  the 
unaffected  side. 

PALPATION. — On  palpation,  no  signs  will  be  obtained  in  the 
early  part  of  -this  stage ;  but  a  little  later  friction  fremitus  may 
frequently  be  detected,  and  the  vocal  fremitus  may  be  found 
to  be  diminished.  Pressure  usually  elicits  deep-seated  tender- 
ness. 

MENSURATION  yields  no  additional  signs. 

PERCUSSION  yields  no  signs  at  first ;  but  when  plastic  exuda- 
tion has  taken  place,  dulness,  in  proportion  to  the  amount  of 
exudation,  will  be  elicited.  The  dulness  is  always  less  marked 
at  the  end  of  forced  expiration  than  during  normal  respiration. 

AUSCULTATION  early  in  this  stage  discovers  a  feeble  respira- 


PLEURISY.  o, 

83 

tory  murmur  with  jerking  or  " cog- wheel"  respiration;  and  in 
some  instances,  just  at  the  end  of  inspiration,  it  reveals  a  feeble, 
grazing  friction  sound.  When  plastic  exudation  has  taken 
place,  the  respiratory  sounds  are  still  more  feeble,  and  the 
friction  sound  becomes  distinct.  The  latter  may  have  any  of 
the  characteristics  of  friction  sounds,  of  which  I  spoke  in  a 
former  lecture,  as,  rubbing,  grazing,  creaking,  or  crackling. 
At  this  stage  of  the  disease,  the  vocal  resonance  is  somewhat 
diminished. 

Signs  of  the  Second  Stage. 

INSPECTION. — In  the  second  stage  of  pleurisy,  we  still  observe 
diminished  respiratory  movements;  but  not  the  interrupted 
respiration,  which  was  noticed  in  the  first  stage. 

PALPATION. — The  vocal  fremitus  is  found  to  be  absent  over 
the  site  of  the  effusion.  In  a  few  instances,  distinct  fluctuation 
can  be  obtained.  The  apex  beat  of  the  heart  will  be  found 
crowded  over  to  the  right  or  to  the  left,  according  to  the 
seat  and  the  amount  of  the  effusion.  If  the  pleurisy  is  upon 
the  left  side,  the  heart  is  crowded  to  the  right;  if  upon  the 
right  side,  it  is  displaced  in  the  opposite  direction. 

Exceptional. — In  very  rare  instances  of  serous  effusion,  the  vocal  fremitus  is  not 

lost. 

PERCUSSION  yields  flatness  over  the  lower  part  of  the  chest, 
and  extending  upward  to  the  surface  of  the  fluid.  The  height 
of  this  surface  is  not  altered  by  deep  inspirations  or  forced 
expirations.  The  relations  of  this  surface  are  changed  by 
alterations  in  the  patient's  position,  the  fluid  tending  to  gravi- 
tate to  the  lower  part  of  the  cavity.  When  the  pleural  sac  is 
*filled  with  fluid,  and  when  there  are  complete  adhesions  above 
the  surface  of  the  liquid,  this  change  will  not  take  place. 

Above  the  fluid,  the  resonance  is  exaggerated  ;  and  in  excep- 
tional cases  it  may  have  a  vesiculo-tympanitic  or  amphoric 
quality. 

Investigations  by  Damoiseau,  of  Paris,  and  more  recently  by 
Dr.  Ellis,  of  Boston,  show  that  usually  when  the  pleural  sac  is 
no  more  than  one  fourth  or  one  third  filled,  the  upper  surface 
of  the  fluid  corresponds  to  a  curved  lined  known  as  the  letter 
"  S  "  curve,  termed  by  Dr.  Ellis  the  curved  line  of  flatness  (Fig. 
19). 


84 


PULMONARY  DISEASES. 


Dr  G  M.  Garland,  in  his  admirable  monograph  on  "  Pneumo- 
Dynamics,"  describes  this  curved  line  as  follows :  "  Its  lowest 


FIG.  19 — Curved  Line  of  Flatness  in  Pleurisy  (Garland). 
C,  B,  letter  S  curve.     A,  B,  C,  triangle  of  dulness. 

point  is  found   behind,  near  the   spinal   column.     From  this 
point,  it  curves  upward  and  outward  across  the  lateral  region, 


FIG.  20. — Curved  Line  of  Flatness  in  Pleurisy  (Ellis). 
Letter  S  curve,  anterior  view. 

where  it  is  highest,  and  from  this  point  it  proceeds  almost  hori- 
zontally forward  to  the  sternum."     The   experiments   of   Dr. 


PLEURISY.  g- 

Garland  demonstrate  that,  instead  of  the  fluid  gradually  rising 
in  the  lower  portion  of  the  chest,  carrying  the  lung  above  it, 
and  maintaining  a  horizontal  surface,  as  is  usually  supposed  ; 
its  upper  line  nearly  corresponds  to  the  natural  outline  of  the 
base  of  the  lung.  This  is  supposed  to  be  due  to  the  elasticity 
of  the  lung,  which  holds  the  fluid  in  this  unnatural  position.  I 
would  refer  those  interested  in  this  matter  to  Dr.  Garland's 
monograph,  for  a  complete  exposition  of  the  subject.  If  a  line 
be  drawn  horizontally  backward  from  the  highest  point  of 
the  curved  line  of  flatness  in  the  lateral  region  to  the  spinal 
column,  a  somewhat  triangular  space  will  be  left  between  it  and 
the  posterior  part  of  the  curved  line  of  flatness.  This  space  is 
termed  by  Dr.  Garland  the  triangle  of  dulness  (Fig.  19,  page 
84).  It  is  bounded  below  and  externally  by  the  letter  "S" 
curve,  internally  by  the  spinal  column,  and  above  by  a  line 
drawn  backward  from  the  highest  point  of  the  curved  line  in 
the  lateral  region.  This  superior  boundary  is  not  necessarily 
horizontal,  but  it  may  be  so  considered  for  the  sake  of  illustra- 
tion. In  this  triangular  space  we  have  no  fluid,  but  the  reso- 
nance is  less  than  above  it.  This  dulness  is  due  to  partial 
compression  of  the  lung  against  the  spinal  column.  In  order 
to  recognize  the  curved  line  throughout  its  entire  extent,  we 
must  not  compare  the  affected  with  the  sound  side  posteriorly, 
as  it  is  not  the  distinction  between  resonance  and  flatness  which 
we  wish  to  obtain,  but  the  distinction  between  dulness  and 
flatness.  Percussion  should  be  made  in  perpendicular  lines  at 
several  places,  either  from  above  downward,  or  from  below 
upward.  By  this  method,  we  can  easily  distinguish  between 
the  dulness  over  the  compressed  lung  and  the  flatness  over 
the  fluid,  and  between  the  character  of  the  resonance  in  these 
positions,  and  that  of  the  lung  above  them.  Failure  to  recog- 
nize the  true  character  of  the  percussion  note  in  these  different 
localities  has  caused  authors  to  describe  the  upper  surface  of 
the  fluid  as  corresponding  to  a  horizontal  line.  If  you  recol- 
lect that  the  fluid  in  the  pleural  sac  conforms  itself  more  or  less 
perfectly  to  the  natural  contour  of  the  base  of  the  lung,  you 
will  understand  why  the  line  does  not  undergo  greater  changes 
with  alteration  in  the  position  of  the  patient.  Suppose,  for 
instance,  that  we  find  the  level  of  the  fluid,  in  front,  at  the  fifth 
rib,  when  the  patient  is  in  an  erect  position :  upon  causing  him 


86 

to  lie  on  his  back,  according  to  the  generally  accepted  opinion 
the  line  of  flatness  should  still  remain  horizontal,  and  would 
then  be  found  running  longitudinally  along  the  lateral  region. 
In  point  of  fact,  however,  this  never  occurs.  On  the  contrary, 
the  line  of  flatness  is  not  likely  to  be  depressed  in  front  more 
than  one  or  two  inches  by  this  change  in  the  patient's  position, 
and  it  will  be  found  running  more  or  less  obliquely  downward 
and  backward,  instead  of  longitudinally. 

When  the  pleural  cavity  is  nearly  filled  with  fluid,  we  fre- 
quently get  tympanitic  resonance  over  its  apex,  especially  if 
the  patient  is  in  a  recumbent  position.  In  attempting  to 
explain  this  phenomenon,  we  are  once  more  involved  in  the 
opposing  statements  that  tympanitic  resonance  is  low-pitched, 
and  that  it  is  high-pitched.  Fraentzel— who  believes  the  tym- 
panitic resonance  to  be  low  in  pitch— in  giving  the  reasons  for 
this  sign,  quotes  from  Wintrich  and  Traube,  who  claim  that  the 
pitch  in  pulmonary  percussion  is  dependent  upon  two  condi- 
tions :  first,  the  volume  of  air  beneath  the  point  percussed  ;  and 
second,  the  tension  of  the  lung  tissue ;  and  also  that  the  pitch 
of  the  percussion  sound  stands  in  direct  proportion  to  the 
tension  and  in  inverse  proportion  to  the  volume  of  the  oscillat- 
ing column  of  air.  In  other  words,  as  the  lung  is  diminished 
in  volume  the  pitch  is  raised ;  or  as  it  again  approaches  the 
normal  size,  the  pitch  is  lowered  according  to  the  amount  of 
air  which  it  contains,  and  as  the  tension  of  the  lung  is  increased 
the  pitch  is  elevated.  Therefore,  if  the  diminution  in  volume 
which  raises  the  pitch,  and  the  diminution  in  tension  which 
lowers  the  pitch,  be  equally  balanced,  the  pitch  will  remain 
unaltered.  It  therefore  follows  that  in  moderately  large  pleu- 
ritic effusions,  which  yield  tympanitic  resonance  in  the  infra- 
clavicular  region,  the  diminution  in  tension  (low  pitch]  must 
exceed  the  diminution  in  volume  (high  pitch}.  Doctors  Flint 
and  Da  Costa,  who  consider  tympanitic  resonance  to  be  of  high 
pitch,  believe  that  this  sign  in  pleurisy  is  due  in  great  part  to 
the  conducted  resonance  from  the  trachea  and  the  bronchial 
tubes.  Both  of  these  reasons  may  be  in  part  correct,  but  as  I 
pointed  out  in  a  communication  to  the  Chicago  Med.  Jour:  and 
Exam.,  March,  1877,  it  is  more  than  probable  that  this  sign 
results  mainly  from  a  collection  of  watery  vapor  above  the 
fluid  in  the  pleural  sac.  You  will  remember  that  vaporization 


PLEURISY.  «„ 

87 

of  water  takes  place  even  at  a  low  temperature,  and  when  we 
reach  a  temperature  of  one  hundred  and  one  or  two  degrees 
Fahrenheit,  under  ordinary  pressure,  vaporization  takes  place 
very  rapidly.  This  process  must  therefore  be  going  on  con- 
stantly when  fluid  collects  in  the  pleural  cavities,  and  as  soon  as 
the  serous  surfaces  become  so  altered  by  inflammation  that  they 
are  incapable  of  absorbing  the  vapor  as  rapidly  as  it  is  formed, 
it  will  collect  above  the  fluid  until  the  tension  becomes  suffi- 
cient to  prevent  its  further  formation.  This  being  the  case,  a 
cavity  is  formed,  filled  with  watery  vapor,  which  must  yield 
tympanitic  resonance.  I  am  convinced  of  the  correctness  of 
this  theory  by  experiments,  not  only  with  fluids  outside  of 
the  body,  but  also  on  a  patient  whose  pleural  cavity  was 
almost  filled  with  fluid,  and  in  whom  tympanitic  resonance 
was  plainly  discernible,  just  beneath  the  clavicle,  when  he  was 
lying  on  his  back.  On  inverting  this  patient,  and  placing 
him  as  nearly  as  possible  upon  his  head,  so  that  the  base 
of  the  chest  was  much  the  highest,  tympanitic  resonance  was 
found  over  a  small  area  at  the  base  of  the  pleural  sac. 

Signs  of  the  Third  Stage. 

During  the  third  stage  of  pleurisy  the  signs  denote  a  gradual 
return  to  a  healthy  condition.  The  distention  becomes  less, 
the  respiratory  movements  are  freer,  and  the  vocal  fremitus 
gradually  returns,  appearing  first  at  the  upper  portion  of  the 
chest.  The  upper  limit  of  the  liquid,  as  ascertained  by  percus- 
sion, slowly  falls  toward  the  lower  part  of  the  chest  until  the 
fluid  is  entirely  absorbed.  Sometimes,  over  the  lower  part  of 
the  chest,  more  or  less  dulness  remains  for  a  long  time,  or  the 
resonance  may  never  become  normal,  owing  to  the  collection 
of  inflammatory  lymph  or  to  thickening  of  the  pleura,  which 
may  permanently  remove  the  lung  a  short  distance  from  the 
chest-wall. 

The  respiratory  sounds  gradually  return,  at  first  feeble  and 
distant,  but  growing  more  and  more  distinct,  until  they  finally 
become  normal.  Occasionally  the  respiratory  sounds  remain 
harsh  and  tubular  in  quality,  on  account  of  the  imperfect  ex- 
pansion of  the  air-vesicles.  Usually,  as  the  two  surfaces  of  the 
pleura  again  come  in  contact,  friction  sounds  are  obtained, 
which  may  continue  for  a  short  time  only,  or  for  several 
months. 


gg  PULMONARY   DISEASES. 

The  heart  and  the  abdominal  organs  gradually  return  to 
their  normal  positions,  as  shown  by  percussion  and  ausculta- 
tion. 

In  some  rare  cases,  however,  when  the  heart  is  crowded  to  the  right  of  the  sternum 
by  an  effusion  into  the  left  pleural  sac,  adhesions  take  place  which  permanently  retain 
the  organ  in  its  abnormal  situation.  Again,  the  absorption  of  a  large  and  long-con- 
tinued effusion  in  the  right  sac  is  sometimes  followed  by  a  permanent  dislocation  of  the 
heart  to  the  right  of  the  sternum,  the  dislocation  being  due  to  the  tendency  of  the  sur- 
rounding parts  to  fill  the  space  which  should  be  occupied  by  the  unexpanded  lung. 

If  the  air-vesicles  do  not  fully  expand,  on  account  of  having 
been  compressed  so  long  that  the  lung  tissue  is  partially  dis- 
organized, or  if  the  lung  cannot  expand  by  reason  of  having  been 
bound  down  by  inflammatory  adhesions,  the  chest  may  never 
again  attain  its  normal  condition.  There  will  be  consequent 
loss  of  motion  and  retraction  of  the  affected  side,  with  more  or 
less  dulness  upon  percussion,  and  feeble  or  suppressed  respira- 
tion. In  the  most  protracted  cases,  the  upper  portion  of  the 
lung  becomes  only  partially  expanded,  and  in  this  region  there 
will  be  more  or  less  dulness  upon  percussion  with  deficient 
vesicular  murmur  and  broncho-vesicular  respiratory  sounds, 
together  with  exaggerated  vocal  resonance. 

TREATMENT. 

The  patient  should  be  kept  quiet.  Talking  should  be  prohib- 
ited and  all  movement  avoided.  The  movements  may  be  re- 
stricted by  strapping  the  side  with  strips  of  adhesive  plaster 
running  diagonally,  from  above  downward  and  forward,  and 
downward  and  backward ;  and  also  horizontally :  a  broad,  elas- 
tic bandage  may  be  employed  for  the  same  purpose.  When 
these  are  not  used,  hot  poultices  may  be  beneficially  employed. 

Opiates  should  be  given  in  sufficient  quantity  to  relieve 
pain.  Saline  diuretics  are  also  important  and  should  be  given 
at  the  same  time.  Sometimes  the  pleural  sac  rapidly  fills 
with  serum,  and  the  question  of  aspiration  will  be  suggested. 
With  regard  to  this,  the  following  rule  is  important :  never 
aspirate  in  acute  pleurisy  until  about  the  middle  of  the  second 
week  or  until  all  acute  symptoms  have  passed.  The  only  excep- 
tion to  this  rule  is  when  we  are  compelled  to  aspirate  to  relieve 
great  dyspnoea.  In  the  latter  stage  of  the  disease,  tonics  and 
le  of  potassium,  with  counter-irritation  by  blisters  or  iodine 
are  indicated.  Absorption  of  the  fluid  may  also  be  favored,  by 


PLEURISY.  gg 

free  sweating  which  may  be  caused  by  jaborandi  or  the  hot 
air  bath ;  and  by  such  diuretics  as  squills,  comp.  spts.  of  juni- 
per, and  bitartrate  or  acetate  of  potassium. 

SUBACUTE    PLEURISY. 

This  is  also  called  chronic  pleurisy  by  some  authors.  It  con- 
sists of  a  low  grade  of  inflammation  of  the  pleura,  most  frequently, 
characterized  by  absence  of  pain  and  slight  constitutional  dis- 
turbance, until  after  extensive  effusion  has  taken  place.  The 
effusion  consists  of  serum,  and  is  usually  very  abundant,  often 
completely  filling  the  pleural  cavity. 

SYMPTOMS. 

The  principal  symptoms  are  dyspnoea,  and  finally  loss  of 
appetite,  emaciation,  vomiting  and  more  or  less  cough. 

It  is  surprising  how  great  the  effusion  may  become  in  this 
affection  before  the  difficulty  in  breathing  becomes  noticeable. 


Bronchial  Breathing. 


Flatness  ;  absence  of  respi- 1 
ratory  and  vocal  sounds.    ) 


Fig.  21. — Subacute  Pleurisy. 
SIGNS. 

The  signs  are  the  same  as  those  of  the  second  and  third  stages 
of  acute  pleurisy  with  extensive  effusion  (Fig.  21). 

TREATMENT. 

The    fluid  should  be  removed  by  the  aspirator.     Iodide  of 
potassium  with  other  diuretics  should  be  given.     Tonics  are 


PULMONARY  DISEASES. 

also  indicated.     Counter-irritation  is  useful.     Every  effort  must 
be  made  to  improve  the  patient's  general  condition. 

CHRONIC   PLEURISY   OR   EMPYEMA. 

In  this  affection  the  inflammation  is  protracted,  and  pus 
instead  of  serum  occupies  the  pleural  sac. 

SYMPTOMS. 

The  symptoms  of  empyema  denote  serious  constitutional 
disturbance.  The  most  important  are :  rapid  pulse,  high  tem- 
perature, dry  brown  tongue,  hectic  and  night  sweats,  with  loss 
of  appetite  and  rapid  emaciation. 

SIGNS. 

The  signs  of  this  disease  are  much  the  same  as  those  of  sub- 
acute  pleurisy,  but  usually  the  displacement  of  the  heart  and  of 
other  adjacent  organs  is  greater.  Ordinarily,  the  level  of  the 
fluid  does  not  vary  with  changes  in  the  position  of  the  patient, 
owing  to  the  agglutination  of  the  pleural  surfaces,  which  has 
taken  place  immediately  above  the  effusion.  In  this,  as  in  other 
varieties  of  pleurisy,  fluctuation  is  occasionally  detected  by 
palpation.  Sometimes  with  large  effusions,  especially  in  the 
left  pleura,  pulsation  of  the  side  is  observed  synchronously  with 
the  contraction  of  the  heart.  This  condition  is  called  pulsat- 
ing empyema.  If  the  pus  breaks  through  the  chest-wall  and 
appears  beneath  the  integuments,  the  tumor  thus  formed 
generally  pulsates  strongly,  and  it  might  easily  be  mistaken  for 
an  aneurism  if  it  happened  to  be  located  in  the  course  of  the 
aorta  instead  6f  occupying  a  position  at  the  lower  part  of  the 
chest.  Tumors  of  this  kind  often  enlarge  with  inspiration  and 
diminish  in  size  with  expiration. 

Exceptional. — Rarely,  empyema  instead  of  occupying  its  usual  position  at  the  base 
of  the  chest,  may  be  confined  to  the  upper  part  of  the  pleural  sac,  or  to  a  small  space 
about  the  root  of  the  lung,  or  it  may  occupy  two  different  and  widely  separated 
localities. 

It  is  generally  considered  impossible  to  differentiate  between  serum  and  pus  in  the 
pleural  sac  ;  but  Prof.  Guido  Bocelli,  of  Rome,  claims  that  the  distinction  can  be  made 
by  attention  to  the  whispering  vocal  resonance.  The  whisper  resonance  he  claims  may 
be  heard  at  the  base  of  serous  pleuritic  effusions,  but  will  not  be  conducted  through 
pus.  In  making  this  distinction,  two  conditions  must  be  complied  with  :  first,  imme- 
diate auscultation  must  be  practiced,  the  ear  being  pressed  firmly  against  the  naked 
chest  and  all  external  sounds  excluded  by  closing  the  other  ear  ;  second,  the  patient 


PLEURISY.  gl 

must  be  so  placed  that  the  vibrations  produced  by  whispering  shall  proceed  from  his 
mouth  in  a  direction  diametrically  opposed  to  the  listening  ear. 

DIFFERENTIAL    DIAGNOSIS    BETWEEN    THE  VARIOUS    FORMS    OF 
PLEURISY   AND   OTHER   DISEASES. 

The  differential  diagnosis  of  pleurisy  is  usually  easy,  yet 
various  diseases  have  been  mistaken  for  it.  The  affections  most 
likely  to  cause  an  error  in  diagnosis  are  pleurodynia,  intercostal 
neuralgia,  pericarditis,  pneumonia,  phthisis,  collapse  of  the  lung 
due  to  pressure  on  a  main  bronchus,  cancer  of  the  lung,  aneu- 
rism of  the  aorta,  and  enlargement  of  the  liver  or  spleen. 

Pleurodynia  and  Intercostal  Neuralgia,. — Pleurisy  is  only  likely 
to  be  mistaken  for  pleurodynia  or  intercostal  neuralgia  in  the 
first  stage  of  the  acute  variety,  when  the  pain  and  consequent 
impairment  of  the  respiratory  movements  and  murmur  are  the 
same  as  in  the  latter  affections.  The  distinction  may  be  made 
by  remembering  that  the  pain  of  pleurodynia  is  likely  to  be 
increased  by  slight  pressure  and  by  muscular  contractions,  and 
that  the  pain  in  intercostal  neuralgia  is  confined  to  one,  two,  or 
three  tender  points  along  the  course  of  the  intercostal  nerves. 
On  the  other  hand,  the  pain  in  pleurisy  is  deep-seated,  and 
although  there  is  tenderness  on  pressure,  it  is  not  confined  to 
isolated  points  over  the  course  of  a  nerve  ;  and  by  auscultation 
we  detect  a  friction  sound  which  is  not  obtained  in  pleurodynia 
or  in  intercostal  neuralgia. 

Pericarditis  is  liable  to  be  mistaken  for  pleurisy  affecting  the 
left  side.  The  diagnosis  between  these  two  diseases  is  based 
upon  the  locality  of  the  pain  and  the  friction  sounds,  and  the 
relation  of  the  latter  to  the  respiratory  movements.  • 

The  pain  of  pericarditis  is  located  in  the  praecordial  region ; 
that  of  pleurisy  more  externally.  The  friction  sound  in  peri- 
carditis is  heard  most  distinctly  at  the  left  border  of  the  sternum 
near  the  fourth  costal  cartilage;  that  of  pleurisy  is  usually 
heard  farther  to  the  left.  The  friction  sound  in  pericarditis  is 
independent  of  the  respiratory  movements,  and  does  not  cease 
when  the  patient  holds  his  breath.  In  pleurisy,  these  sounds 
are  not  heard  at  all  except  during  respiration. 

Exceptional.— The  action  of  the  heart  may  cause  a  friction  sound  between  the 
anterior  portions  of  the  left  pleura  which  will  not  disappear  when  respiration  ceases, 

but  this  is  extremely  uncommon. 

Pneumonia.— Pleurisy  is  distinguished   from   pneumonia   by 


PULMONARY   DISEASES. 

the  signs  obtained  on  palpation,  percussion,  and  auscultation. 
These  are :  vocal  fremitus  feeble  or  absent,  instead  of  exagger- 
ated, flatness  instead  of  dulness,  change  in  the  level  of  the  liquid 
by  altering  the  position  of  the  patient,  and  absence  of  respira- 
tory and  vocal  sounds  instead  of  bronchial  breathing,  bron. 
chophony,  and  rales.  See  page  124. 

Phthisis.— Pleurisy  is  distinguished  from  phthisis  by  the  same 
signs  which  discriminate  it  from  pneumonia,  and  by  the  fact 
that  phthisis,  affecting  the  greater  part  of  the  lower  lobe  of  One 
lung,  will  also  affect  the  apex  of  the  opposite  lung,  whereas  the 
signs  of  pleurisy  are  usually  confined  to  the  lower  part  of  one 
side.  In  phthisis  the  signs  usually  progress  downward;  in 
pleurisy  they  proceed  upward. 

Collapse  of  the  Lung. — Collapse  of  one  lung  from  compression 
of  its  main  bronchus  may  present  many  signs  similar  to  those 
found  in  pleurisy  with  extensive  effusion,  viz.,  loss  of  motion  of 
the  side,  absence  of  vocal  fremitus,  flatness  on  percussion,  and 
absence  of  respiratory  and  vocal  signs.  When  these  signs  exist, 
the  diagnosis  must  be  based  mainly  on  the  position  of  the 
heart.  Moderate  pleuritic  effusions,  where  no  adhesion  of  the 
pleural  surfaces  has  taken  place,  would  be  easily  differentiated 
from  the  condition  under  consideration  by  changes  in  the  level 
of  the  fluid.  But  where  the  effusion  is  circumscribed,  or  when 
it  completely  fills  the  pleural  cavity,  this  sign  would  not  be 
present.  In  pleurisy  with  considerable  effusion,  the  heart  is 
more  or  less  displaced  toward  the  opposite  side.  This  does 
not  occur  in  collapse  of  the  lung.  The  essential  difference 
in*  the  signs  of  these  two  conditions  may  be  seen  at  a  glance  in 
the  following  table  :* 

PLEURISY.  COLLAPSE  OF  LUNG  FROM  COMPRESSION 

OF  THE  MAIN  BRONCHUS. 

Heart  usually  more  or  less  displaced  to  Heart  not  displaced, 

opposite  side. 

Side  often   distended.      Side   not   re-  Side  not  distended,  may  be  retracted, 

traded  excepting  in  protracted  cases.  and  would  always  be  retracted  except  that 

collapse  of  the  air-vesicles  causes  dimin- 
ished pressure  on  the  organ.  This  favors 
dilatation  of  the  blood-vessels,  and  causes 
congestion  with  exudation  which  fills  the 
air-vesicles  and  distends  the  lung  to  its 
_____ ,  normal  size. 

*  In  this,  as  in  other  tables,  signs  common  to  both  diseases  have  been  omitted. 


PLEURISY,  . 

Pulmonary  Cancer. — In  this  affection  dulness  usually  begins 
near  the  middle  of  the  lung  and  progresses  irregularly  in  dif- 
ferent directions,  leaving  here  and  there  patches  or  islands  of 
normal  resonance  surrounded  by  flatness.  Observe  that  in 
pleurisy  flatness  begins  at  the  base  of  the  chest  and  is  uniform. 
The  constitutional  symptoms  of  the  two  diseases  are  very 
different. 

Aneurism  of  the  Aorta. — The  occurrence  of  empyema  with 
perforation  of  the  chest  walls,  in  the  course  of  the  aorta,  might 
cause  a  tumor  which  would  closely  simulate  aneurism.  It  would 
be  distinguished  from  the  latter  disease  by  the  presence  of 
signs  of  empyema  in  the  lower  part  of  the  chest.  In  all  proba- 
bility you  will  never  be  called  upon  to  make  a  diagnosis  in  such 
a  case. 

Enlargement  of  the  Spleen  is  distinguished  from  pleurisy  of  the 
left  side  by  attention  to  the  following  facts.  An  enlarged  spleen 
seldom  encroaches  much  upon  the  thorax,  and  therefore  it 
causes  little  or  no  distention  of  the  side,  and  no  bulging  of  the 
intercostal  spaces,  or  displacement  of  the  heart.  Upon  percus- 
sion, dulness  is  found  to  extend  in  front  higher  than  behind, 
and  the  level  of  its  upper  surface  does  not  materially  change 
with  changes  in  the  patient's  position. 

Enlargement  of  the  Liver  has  frequently  been  mistaken  for 
pleuritic  effusions,  even  by  skilful  diagnosticians.  The  differ- 
ential signs  will  be  seen  in  the  following  table : 

PLEURITIC  EFFUSIONS.  HYPERTROPHY  OF  THE  LIVER. 

Inspection. 

Frequently  bulging   of   the  intercostal  There  may  be  bulging  of  the  chest,  but 

spaces.  the   intercostal    spaces   are  not  specially 

prominent. 

Palpation. 
Occasionally  fluctuation.  No  fluctuation. 

Percussion. 

Dulness  extending  higher  behind  than  in  Dulness  extending  in  front  higher  than 

front,  behind,   because   the   shelving  border  of 

the  lung  posteriorly  intervenes  between 
the  liver  and  the  thoracic-walls. 

The  line  of  absolute  flatness   usually  The  line  of  flatness  is  not  materially 

varies  with  changes  in  the  position  of  affected  by  changes  in  the  patient's  posi- 
the  patient,  and  is  not  depressed  or  ele-  tion,  but  is  depressed  and  elevated  by 
vated  during  inspiration  or  expiration.  inspiration  and  expiration. 


PULMONARY   DISEASES. 

y^ 

Auscultation. 

The  respiratory   murmur  is   heard   in  The  respiratory  murmur  is   heard  be- 

front,  at  a  lower  level  than  behind,  and  hind,  at  a  lower  level  than  in  front,  and 
this  level  is  not  materially  affected  by  this  level  is  depressed  during  deep  inspi- 
deep  inspiration.  ration  and  elevated  in  expiration. 

TREATMENT   OF   EMPYEMA. 

When  pus  collects  in  the  pleural  sac  it  should  be  removed. 
At  first  an  exploratory  operation  by  means  of  the  aspirator 
should  be  made,  and  as  soon  as  the  pus  re-collects  free  drainage 
should  be  established.  The  cavity  should  be  cleansed  daily, 
or  twice  daily,  with  a  one-per-cent  solution  of  carbolic  acid  in 
water  at  100°  F.  If  healing  does  not  soon  occur,  stimulating 
injections  should  be  used.  For  this  purpose  we  may  employ 
sulphate  of  zinc,  gr.  ij.-iv.  to  the  ounce  of  water ;  sulphate  of 
iron,  gr.  iv.-viij.  ad  f  i.;  compound  solution  of  iodine,  3  ss.-  3  i- 
ad  §  i.,  and  similar  substances. 

When  one  of  these  remedies  loses  its  effects,  as  it  ordinarily 
will  in  two  or  three  weeks,  another  must  be  tried,  and  when 
weak  solutions  fail  to  stimulate  the  healing  process,  stronger 
ones  must  be  substituted.  Attention  should  always  be  given 
to  the  patient's  general  health. 

The  following  forms  of  pleurisy,  though  not  entitled  to  be 
considered  as  distinct  varieties,  need  some  special  considera- 
tion : 

Circumscribed  Pleurisy  usually  occurs  during  the  course  of 
phthisis,  and  is  responsible  for  many  of  the  acute  pains  suffered 
by  consumptives.  This  inflammation  is  generally  limited  to 
the  small  portion  of  pleura  investing  that  portion  of  the  lung 
where  the  lesions  are  superficial.  The  signs  indicating  this 
condition  are  some  variety  of  friction  sound,  or  a  dry,  creaking 
sound,  probably  due  to  old  adhesions. 

Pleurisy  of  the  Apex,  unassociated  with  phthisis,  is  said  by 
Dr.  J.  Burney  Yeo  to  be  a  frequent  disease,  which  he  believes 
to  be  the  cause  of  many  coughs,  usually  called  "  hysterical  "  or 
"  stomach  coughs."  He  has  observed  it  principally  in  women 
who  have  been  accustomed  to  wear  low-necked  dresses. 

SYMPTOMS. 

A  harsh,  dry,  shallow  or  incomplete  cough,  occurring  in  a 
person  apparently  in  good  health. 


PLEURISY. 
SIGNS. 

The  only  physical  sign  to  be  detected  is  friction  limited  to 
the  supra-clavicular  region,  or  to  the  upper  third  of  the  scap- 
ular. 

Diaphragmatic  Pleurisy.— Inflammation  of  that  portion  of 
the  pleura  which  covers  the  diaphragm  is  not  easily  detected. 
I  wish  to  direct  your  special  attention  to  a  few  symptoms  and 
signs  which,  according  to  Dr.  Noel  Gueneau,  render  its  diag- 
nosis more  precise.  Besides  the  pain  elicited  by  pressing  over 
the  base  of  the  chest  on  the  affected  side,  there  is  a  point  of 
hyperaesthesia,  due  to  irritation  of  the  phrenic  nerve,  which  is 
found  at  the  intersection  of  two  lines,  one  of  which  corresponds 
to  the  border  of  the  sternum,  and  the  other  of  which  is  perpen- 
dicular to  the  first,  and  follows  and  prolongs  the  border  of  the 
ribs.  At  the  same  time,  exaggerated  sensibility  is  found  be- 
tween the  sternal  attachments  of  the  sterno-cleido-mastoid  mus- 
cles, and  pain  is  experienced  in  the  shoulder  and  in  the  infra- 
clavicular  region  of  the  same  side.  This  is  due  to  reflex 
action,  caused  by  irritation  of  the  phrenic  nerve.  Neuralgia 
of  the  last  intercostal  nerve  is  also  frequently  present,  and  there 
is  likely  to  be  increased  obliquity  of  the  last  rib  on  the  affected 
side,  and  immobility  of  the  hypochondrium.  If  the  inflamma- 
tion is  on  the  right  side,  the  liver  is  usually  slightly  depressed. 

PERCUSSION  gives  a  high-pitched  note  over  a  narrow  space, 
corresponding  to  the  lower  margin  of  the  lung  contiguous  to 
the  effusion. 

AUSCULTATION. — On  auscultation,  the  vesicular  sound  at  the 
level  of  the  collection  of  liquid  is  usually  feeble,  and  accom- 
panied with  crepitant  or  mucous  rales..  Weakness  of  the  inspi- 
ratory  sound  and  prolonged  expiration  may  exist  over  the 
whole  lung,  due  to  compression  of  the  bronchi  by  enlarged 
glands,  which  are  said  ordinarily  to  accompany  this  disease. 

Multilocular  Pleurisy.— In  1854,  Prof.  Wintrich  wrote  that 
it  was  impossible  to  distinguish,  in  the  living  subject,  between 
unilocular,  bilocular,  and  multilocular  pleurisies,  and  this  pro- 
position is  still  generally  accepted ;  but  recently  it  has  been 
asserted  that  the  diagnosis  is  practicable  in  many  instances. 
In  a  communication  to  the  Academic  de  Medicine  of  Paris  in 
1879,  M.  Jaccoud  declared  the  diagnosis  possible,  when  the 


^  PULMONARY   DISEASES. 

following  groups  of  signs  are  found  coincidently  with  the  ordi- 
nary symptoms  and  signs  of  pleurisy.  He  had  observed  two 
distinct  semeiological  types  of  the  affection. 

In  the  first,  added  to  the  ordinary  signs  of  complete  pleuritic 
effusions,  the  vocal  fremitus,  though  lost  over  every  other  por- 
tion of  the  affected  side,  is  found  to  be  preserved  along  a  line 
running  forward  from  the  spinal  column,  in  a  more  or  less  reg- 
ular semi-circular  course,  toward  the  sternum,  at  a  variable 
height.  Vocal  resonance  and  bronchial  respiration  are  heard 
in  the  same  locality,  though  wanting  everywhere  else. 

This  line  indicates  the  position  of  the  band  of  pleural  adhe- 
sion which  divides  the  pleural  sac  into  two  cavities.  In  these 
cases,  he  has  found  in  the  infra-clavicular  region  feeble  and 
distant  respiratory  murmur  and  voice-sounds,  with  no  tympa- 
nitic  resonance. 

In  the  second  type,  vocal  fremitus,  though  more  or  less 
enfeebled,  is  obtained  over  the  whole  effusion,  excepting,  some- 
times, a  narrow  zone,  one  or  two  fingers  in  breadth,  at  the 
lower,  posterior  part  of  the  chest.  Marked  bronchial  respira- 
tion and  bronchophony  are  also  found  over  the  fluid,  with 
perfect  flatness  on  percussion,  and  no  tympanitic  resonance 
under  the  clavicle.  In  two  cases  he  has  been  able  to  locate  the 
fundamental  partitions,  by  finding  one  or  two  zones  where  the 
vibrations  were  manifestly  stronger  than  in  other  localities. 
The  value  of  this  diagnosis  depends  upon  the  proposition 
apparently  established  by  M.  Jaccoud's  observations,  that 
thoracentesis  is  not  well  borne  in  multilocular  pleurisy,  but 
that  it  seems  rather  to  add  greatly  to  the  patient's  danger. 
The  essential  points  in  the  differential  diagnosis  between  exten- 
sive pleuritic  effusions  of  the  unilocular,  bilocular,  and  multi- 
locular types,  are  shown  in  the  following  table. 

UNILOCULAR  PLEURISY.         BILOCULAR  PLEURISY.        MULTILOCULAR  PLEURISY. 

Palpation. 

Loss  of  vocal  fremitus.  Vocal  fremitus  preserved         Vocal    fremitus,     though 

on  a  line  corresponding  with     enfeebled,  is   present   over 

the  band  of  adhesion,  though     the  whole   of   the    affected 

lost   above   and  below  this     side,  excepting  a  small  zone 

line.  at  the  base.    Vocal  fremitus 

is  occasionally  well  marked 

in  one  or  two  limited  zones 

corresponding  to  bands  of 

adhesion. 


HYDROTHORAX. 


97 


Usually  tympanitic    reso- 
nance under  the  clavicle. 


Absence  of  respiratory 
murmur  and  vocal  reso- 
nance, excepting  over  the 
compressed  lung  in  the  up- 
per part  of  the  thorax. 


Percussion . 

Flatness  over  the  whole 
chest ;  no  tympanism. 

Auscultation. 
Bronchial  respiration,  and 
bronchophony  heard  over  a     bronchophony  marked  over 
line    corresponding   to    the     the  seat  of  the  whole  effu- 
pleuritic  band,  but  wanting     sion. 
in  other  places,  except  over 
the   apex,   where   they   are 
indistinct. 


Flatness  over  the  whole 
chest  ;  no  tympanism. 

Bronchial  respiration  and 


HYDROTHORAX. 

This  term  is  properly  applied  only  to  dropsical  effusions, 
which  will  affect  both  sides  alike,  causing  the  same  signs  as 
pleuritic  effusions  of  an  inflammatory  character. 

TREATMENT. 

The  proper  remedial  measures  are  those  suited  to  the  condi- 
tion which  has  caused  the  dropsy,  and  aspiration  to  relieve  the 
lungs  from  pressure. 


LECTURE  X. 
DISEASES  OF  THE  LUNGS— Continued. 

PNEUMOTHORAX. 

Pneumothorax  consists  of  a  collection  of  air  or  gas  in  the 
pleural  sac,  resulting  from  perforation  of  the  pleura,  or  from 
decomposition  of  pleuritic  effusions  (Fig.  22). 

SYMPTOMS. 

The  usual  symptoms  are  sudden  acute  pain  in  the  side,  with 
severe  dyspnoea  and  iividity  of  the  lips  and  face  ;  great  prostra- 
tion, accompanied  with  anxiety  of  countenance;  a  clammy 
surface,  palpitation  of  the  heart,  and  accelerated  pulse. 


Amphoric  sounds.  1 
Metallic  tinkling,  j 


Flatness. 


P ig.  22. — Pneumo-hydrothorax. 

lung  compressed  by  air  and  fluid.      Heart  crowded  far  to  the  left. 
SIGNS. 

The  most  important  signs  are  diminished  movement  and  en- 
*rgement  of  the  affected  side;  tympanitic  resonance;  respira- 
>ry  murmur  feeble,  or  amphoric  in  character,  or  wantino- 

INSPECTION   AND    MENSURATION    reveal  distention  of  the 


PNEUMO-HYDROTHORAX. 

affected  side,  diminution  or  loss  of  the  respiratory  movements, 
with  widening,  and  sometimes  bulging  of  the  intercostal 
spaces. 

PALPATION. — The  vocal  fremitus  is  feeble  or  wanting,  and 
the  apex  beat  of  the  heart  is  displaced  toward  the  sound  side. 

PERCUSSION.— Tympanitic  or  amphoric  resonance  is  obtained 
over  the  collection  of  air.  When  the  distention  of  the  side  is 
extreme,  the  adjacent  organs  are  displaced,  and  the  tympanitic 
resonance,  somewhat  muffled  and  modified  in  quality,  may  be 
obtained  for  a  considerable  distance  beyond  the  normal  limits 
of  the  pleura. 

Exceptional. — Occasionally  when  the  tension  is  very  great,  the  percussion  note  is  so 
muffled  as  to  seem  almost  dull.  The  bell  sound  may  be  obtained  by  percussion  with 
two  coins  on  one  side  of  the  cavity  while  the  ear  is  placed  opposite. 

AUSCULTATION. — The  respiratory  murmur  is  feeble  or  absent 
according  to  the  amount  of  air.  The  vocal  sounds  are  altered 
in  like  manner.  The  respiratory  murmur  on  the  sound  side  is 
exaggerated.  The  heart  sounds  are  feebly  transmitted  through 
the  collection  of  air.  Bronchial  breathing  may  be  heard  over 
the  compressed  lung,  in  the  inter-scapular  space,  and  usually 
over  the  apex  anteriorly.  Amphoric  respiration  and  voice  are 
also  obtained  when  a  bronchial  tube  connects  freely  with  the 
cavity  of  the  pleura.  For  the  differential  diagnosis  between 
this  and  emphysema,  the  only  disease  with  which  it  is  likely  to 
be  confounded,  see  page  101. 

PNEUMO-HYDROTHORAX. 

This  name  signifies  a  collection  of  both  fluid  and  air  in  the 
pleural  sac.  As  the  effusion  of  fluid  is  almost  sure  to  follow 
in  a  few  hours  after  the  admission  of  air  into  the  pleura,  the 
signs  and  symptoms  of  this  disease  and  of  pneumothorax  are 
usually  considered  together.  But  the  presence  of  both  air  and 
fluid  in  the  pleural  cavity  causes  some  signs  which  are  not 
found  in  pneumothorax.  The  sound  obtained  by  SUCCUSSION 
is  diagnostic.  Metallic  tinkling  is  also  found  in  many  instances 
(Fig.  22). 

INSPECTION,  PALPATION,  AND  MENSURATION  furnish  the  same 
signs  as  those  found  in  pneumothorax,  or  in  extensive  pleuritic 
effusions.  There  is  absence  of  vocal  fremitus,  and  there  is  dis- 


PULMONARY   DISEASES. 

placement  of  the  heart  and  adjacent  organs,  with  distention  of 
the  side,  and  loss  of  motion. 

PERCUSSION.— On  percussion,  tympanitic  resonance  is  c 
tained  over  the  air  in  the  upper,  and  flatness  over  the  fluid  in  the 
lower  portions  of  the  chest.  The  line  of  flatness  corresponding 
to  the  surface  of  the  fluid  changes  by  alterations  in  the  position 
of  the  patient.  Tympanitic  resonance  is  not  unfrequently 
transmitted  a  short  distance  beyond  the  limits  of  the  pleura,  and 
even  below  the  surface  of  the  fluid,  so  that  if  only  a  small  effu- 
sion is  present,  this  sign  may  be  heard  over  the  entire  chest,  and 
thus  the  presence  of  fluid  may  escape  our  notice.  Amphoric 
resonance  is  sometimes  heard  over  the  upper  part  of  the  chest. 

AUSCULTATION. — Upon  auscultation,  below  the  level  of  the 
fluid,  the  respiratory  murmur  is  absent  or  is  very  feeble  and 
distant.  Above  this  level  it  may  be  the  same,  or  amphoric  res- 
piration'may  be  heard.  This  latter  may  be  limited  to  a  small 
space  near  the  point  of  perforation,  which  is  likely  to  be 
located  just  in  front  of  the  angle  of  the  fourth  or  fifth  rib. 
Amphoric  respiration  may  disappear,  and  reappear  again,  dur- 
ing the  course  of  the  disease  in  consequence  of  the  variation 
in  the  amount  of  fluid  from  day  to  day. 

Usually  bronchial  respiration  is  heard  over  the  compressed 
lung,  where  it  lies  against  the  spinal  column. 

The  signs  of  phthisis,  which  in  nine  cases  out  of  ten  precede 
pneumothorax,  are  frequently  found  at  the  apex  of  the  lung 
on  the  opposite  side.  Metallic  tinkling,  due  to  dropping  of 
fluid  from  the  upper  portion  of  the  cavity  into  the  effusion  at 
its  lower  part,  is  one  of  the  signs  of  this  disease  ;  and  the  splash- 
ing sound  obtained  on  succussion  is  characteristic.  Vocal  reso- 
nance is  feeble  or  wanting,  or  amphoric,  upon  the  affected  side. 
The  percussion  resonance  and  the  respiratory  murmur  upon 
the  sound  side  are  exaggerated. 

DIFFERENTIAL   DIAGNOSIS. 

Pneumothorax  and  pneumo-hydrothorax  are  not  likely  to  be 
mistaken  for  other  diseases,  though  they  are  said  to  be  closely 
simulated  when  there  is  complete  catarrhal  obstruction  of  the 
main  bronchus  on  one  side.  They  may  possibly  be  mistaken 
for  emphysema,  chronic  pleurisy,  or  diaphragmatic  hernia. 

Emphysema  presents  the  following  distinctive  features: 


PNEUMO-HYDROTHORAX.  ,o, 

PNEUMOTIIORAX  AND   PNEUMO-HYDRO-  EMPHYSEMA. 

THORAX. 

Inspection. 

Prominence  or  bulging  of  one  side  with  Prominence  of  the  anterior  superior  por- 

loss  of  movement,  especially  at  the  lower  tion  of  the  chest,  usually  upon  both  sides, 
part  of  the  chest,  but  no  falling-in  of  the  with  a  characteristic  lifting  movement  or 
inferior  ribs  or  intercostal  spaces  during  the  upper  part  and  falling-in  of  the  lower 
inspiration.  ribs  and  intercostal  spaces  during  inspira- 

tion, with  frequently  permanent  contrac- 
tion of  the  lower  part  of  the  chest. 
Percussion. 

Tympanitic  resonance  over  the  upper  Vesiculo-tympanitic  resonance  over  the 

part  of  the  chest  with  flatness  over  the         entire  lung,  but  most  marked  at  the  su- 
fluid,    the   line   of  flatness   varying  with         perior  portions  ;  no  flatness  below.     The 
changes  in  the  patient's   position.     The         heart  may  be  covered  by  lung  tissue,  but 
heart  is  displaced  to  the  right  or  to  the         it  is  not  greatly  displaced.     The  signs  are 
left,  according  to  the  seat  of  the  disease.         usually  found  on  both  sides. 
Nearly  always  these  signs  are  found   on 
one  side  only. 

Auscultation. 

Respiratory  murmur  feeble  or  absent ;  Respiratory  murmur  usually  feeble  and 

if  heard,  the  expiratory  murmur  is  of  nor-  generally  associated  with  bronchial  rales, 

mal  duration,  unless  prolonged  by  consol-  The  expiratory  sound  is  prolonged  and 

idation  of  the  lung,  in  which  case  it  will  low-pitched.     The  respiratory  sounds  are 

be   high-pitched.      Amphoric   respiration  sometimes  harsh  and  tubular,  but  never 

and  voice  are  observed  if  a  bronchial  tube  amphoric.     No  metallic  tinkling, 
connects   freely  with    the  pleural  cavity. 
Metallic  tinkling. 

Sitccussion. 

Splashing  sounds  if  fluid  is  present.  No  splashing  sound. 

Chronic  Pleurisy. — These  diseases  can  be  easily  distinguished 
from  chronic  pleurisy  by  the  physical  signs  obtained  on  percus- 
sion and  auscultation.  On  inspection,  palpation,  and  mensura- 
tion the  signs  are  similar. 

PNEUMOTHORAX  AND   PNEUMO-HYDRO-  CHRONIC  PLEURISY. 

THORAX. 

Percussion. 

Tympanitic  resonance  over  the    upper  Tympanitic  resonance,  if  heard  at  all, 

portion  of  the  chest,  flatness  over  the  is  limited  to  a  small  space  at  the  apex  of 
fluid.  the  lung,  usually  immediately  beneath  the 

clavicle  ;  flatness  over  the  remainder  of 
the  affected  side. 

Auscultation. 
Often  amphoric  respiration  and  voice.  Never  amphoric  respiration  or  voice. 

Diaphragmatic  Hernia  is  fortunately  a  rare  disease,  otherwise 
it  would  frequently  be  mistaken  for  pneumothorax,  with  which 


COLLEG 
PHYSIC 


PULMONARY   DISEASES. 

it  possesses  many  symptoms  and  signs  in  common.  This  affec- 
tion, like  pneumothorax,  causes  distention  of  one  side  with 
diminished  motion,  tympanitic  resonance,  and  feeble  or  sup- 
pressed respiration  with  metallic  tinkling.  The  diagnosis  de- 
pends mainly  upon  the  history  and  the  symptoms,  as  will  be 
seen  from  the  following  table : 

PNEUMOTHORAX.  DIAPHRAGMATIC  HERNIA. 

History  and  Symptoms. 

Usually  follows  phthisis  or  accidental  Often   congenital ;    at  times   dyspnoea 

perforation  of  pleura ;  the  dyspnoea  may  comes  on  suddenly,  and  as  suddenly  dis- 
come  on  suddenly  or  gradually.  appears. 

Auscultation. 

Amphoric  respiration  and  metallic  tink-  No  amphoric  respiration,  and  the  metal- 

jing  lie   tinkling    occurs   independent   of   the 

respiratory  movements,  and  is  associated 
with  rumbling  of  gas  in  the  stomach  or 
intestines ;  which  usually  form  the  con- 
tents of  the  hernia. 

TREATMENT. 

Pneumothorax  and  pneumo-hydrothorax  call  for  essentially 
the  same  treatment.  At  first  an  opiate  should  be  administered 
to  relieve  pain.  When  fluid  has  collected  and  dyspnoea  is 
great,  free  drainage  is  advisable,  especially  if  the  fluid  has  be- 
come purulent :  subsequently  the  case  should  be  treated  in  the 
same  manner  as  empyema. 

ACUTE   BRONCHITIS. 

Bronchitis  is  an  inflammation  of  the  membrane  lining  the 
bronchial  tubes.  It  affects  both  sides  at  the  same  time,  and  is 
therefore  called  a  bilateral  disease.  Four  varieties  are  recog- 
nized, viz.,  subacute,  acute,  chronic,  and  capillary  bronchitis. 
The  symptoms  and  the  signs  of  acute  and  subacute  bronchitis 
are  substantially  the  san\e,  except  that  in  the  latter  variety  they 
are  less  marked. 

SYMPTOMS. 

The  disease  is  ushered  in  sometimes  with  a  chill ;  usually  with 
pain  in  the  back  and  extremities,  attended  by  tightness  or  con- 
striction in  the  chest,  soreness  beneath  the  sternum,  a  harsh 
cough  and  frothy  expectoration  sometimes  streaked  with  blood. 

SIGNS. 

The  most  important  signs  are  absence  of  dulness  and  the 


ACUTE    BRONCHITIS.  IO3 

presence  of  large  and  small,  dry  or  moist,  rales  on  both  sides 
of  the  chest  (Fig.  17,  page  67). 

INSPECTION. — In  acute  bronchitis  the  movements  of  the  chest 
are  normal  or  somewhat  accelerated. 

PALPATION. — Upon  palpation  the  vocal  fremitus  is  normal. 
If  there  is  considerable  secretion  in  the  tubes,  ronchial  fremitus 
will  be  obtained,  especially  in  children. 

Exceptional. — In  a  few  cases  the  movements  are  deficient  in  those  parts  of  the 
chest  which  are  supplied  by  bronchi  that  are  partially  occluded  by  a  collection  of  the 
bronchial  secretions. 

PERCUSSION. — On  percussion  the  resonance  is  normal. 

Exceptional. — In  some  cases  dulncss  is  found  especially  over  the  lower  portion  of 
the  chest,  due  to  accumulation  of  the  fluid  secretions.  This  dulness,  however,  is  not 
permanent,  as  it  may  be  removed  by  coughing  and  free  expectoration. 

AUSCULTATION. — By  auscultation  in  subacute  bronchitis  we 
frequently  hear  simply  a  harsh  and  somewhat  bronchial  sound 
without  any  rales.  In  acute  bronchitis,  and  in  many  cases  of 
the  subacute  affection,  dry  sonorous  and  sibilant  rales  (Fig.  17, 
page  67)  are  obtained  in  the  early  part  of  the  disease,  and  the 
vesicular  murmur  is  more  or  less  drowned  by  these  signs. 
After  from  twenty -four  to  forty-eight  hours,  the  secretions  from 
the  mucous  membrane  become  abundant,  and  then  the  dry 
rales  give  place  to  large  and  small,  moist,  mucous  rales.  The 
intensity  of  these  rales  varies;  sometimes  they  are  feeble,  at 
other  times  they  may  be  heard  at  quite  a  distance  from  the 
chest.  These  signs  are  seldom  continuous.  Often  they  are 
heard  during  a  few  respirations,  and  are  then  displaced  by 
deep  inspiration  or  by  forced  expiration  or  cough.  Mucous 
rales,  even  when  numerous,  may  sometimes  be  entirely  removed 
by  free  expectoration. 

Some  of  the  bronchial  tubes  may  become  so  filled  with 
mucus  as  greatly  to  diminish  the  intensity  of  the  vesicular 
murmur,  or  even  to  suppress  it  in  those  portions  of  the  lung 
which  are  supplied  by  the  occluded  bronchus. 

Exceptional.— -If  the  disease  affects  the  smaller  tubes,  the  vesicular  murmur  may  be 

inaudible  over  the  entire  chest. 

Vocal  resonance  is  not  altered  by  this  disease. 


PULMONARY    DISK  ASKS. 
104 


CHRONIC   BRONCHITIS. 

The  prominent  symptoms  are  cough,  some  dyspnoea,  muco- 
purulent  expectoration,  often  without  an)'  considerable  consti- 
tutional disturbance.  The  signs  of  chronic  bronchitis  differ 
from  those  of  the  acute  affection,  principally  in  the  greater 
abundance  of  mucous  rales,  and  in  the  scarcity  of  dry  rales. 

DIFFERENTIAL   DIAGNOSIS. 

The  different  varieties  of  bronchitis  may  be  readily  distin- 
guished from  each  other  by  the  history.  They  are  liable  to 
be  mistaken  for  asthma,  emphysema,  pulmonary  hemorrhage, 
and  phthisis. 

Asthma. — From  asthma  they  are  distinguished  by  the  symp- 
toms and  by  the  history.  The  spasmodic  character  of  asthma, 
its  sudden  appearance,  the  great  dyspnoea,  and  the  history  of 
former  attacks  are  sufficient  to  establish  the  diagnosis.  The 
physical  signs  in  these  two  diseases  differ  rather  in  degree  than 
in  kind,  as  shown  in  the  following  table : 

BRONCHITIS.  ASTHMA. 

In  the  early  stage  there  are  dry  rales,  During  the  paroxysm  the  sonorous  and 

comparatively*  few   in   number.      Later,  sibilant   rales   are   very  abundant.     The 

during  the  second  or  third  day,  dry  rales  following  day  either  the  respiratory  niui- 

give  place   to  large   and   small   mucous  mur  may  be  normal  or  an  abundance  of 

rales.  moist  rales,  due  to  the  attendant  bronchi- 
tis, may  be  present. 

Empiiyscma.— Simple  bronchitis  can  be  easily  distinguished 
from  well-marked  cases  of  emphysema,  but  the  latter  disease 
is  usually  associated  with  more  or  less  inflammation  of  the 
bronchial  mucous  membrane.  The  distinctive  points  in  the 
two  diseases  will  be  seen  below  : 

BRONCHITIS.  EMPHYSEMA. 

Inspection . 

The  form  and  movements  of  the  chest  Prominence  of   the  upper  portions  of 

are  natural.  t]ie  che:>t  "barrel-shaped,"  with  more  or 

less  constant  expansion  of  the  superior 
ribs,  which  are  elevated  in  inspiration  as 
though  united  in  a  single  bone.  Depres- 
M  >n  of  the  soft  parts  in  inspiration,  nota- 
bly above  the  clavicles  and  sternum,  and 
at  the  lower  portions  of  the  chest . 


CHRONIC   BRONCHITIS.  JQJ 

Percussion . 

The   resonance    is  normal.     In  excep-  Vesiculo-tympanitic  resonance  more  or 

tional  instances  slight  clulness,  especially  less  marked. 
over  the  lower  part  of  the  chest. 

A  uscultation. 

Vesicular    murmur   sometimes    incom-  The  respiratory  sounds  feeble,  but  ex- 

plete.     The  expiratory  murmur  not  pro-  piration    greatly    prolonged.      Compara- 

longed.     Numerous  rales.  tively  few  rales. 

Hemorrhage  into  the  Bronchi. — Bronchitis  is  distinguished  from 
hemorrhage  into  the  bronchial  tubes  by  the  character  of  the 
sputa.  The  physical  signs  are  identical,  except  the  absence 
in  the  latter  of  dry  rales,  with  the  harsh  quality  of  respiration 
often  found  in  bronchitis. 

P/tthisis.—^eioi'Q  the  days  of  auscultation  and  percussion, 
chronic  bronchitis  was  often  mistaken  for  phthisis,  but  at  pres- 
ent the  physical  signs  render  their  distinction  comparatively 
easy.  They  differ  in  the  following  particulars: 

BRONCHITIS.  PHTHISIS. 

Inspection. 

The  form  and  movements  of  the  chest  Very  early  in  the  disease  more  or  less 

are  natural.  depression  over  the  affected  region,  with 

lessened  expansion. 
Palpation. 

The    ronchial    fremitus,   with    normal  Vocal  fremitus  exaggerated. 

vocal  fremitus. 

Percussion . 

The  resonance  normal.  More  or  less  dulness  over  the  affected 

regions. 

Auscultation. 

The   rales   found    in    this   disease   are  The  rales,  and  other  signs  of  consoli- 

equally  diffused  over  both  lungs.  The  dation,  are  localized,  being  limited  to  the 
expiratory  murmur  is  not  notably  pro-  portion  of  lung  affected.  There  is  bron- 
longed.  Vocal  resonance  natural.  cho-vesicular  respiration,  and  exaggerated 

vocal  resonance. 

TREATMENT. 

In  many  cases  the  acute  disease  may  be  aborted,  if  taken 
early,  by  Dover's  powder  gr.  x.,  or  quinine  gr.  x.,  or  a  hot  sling 
at  bed  time.     If  this  fails,  small  doses  of  opium  or  of  aconit< 
are  very  useful  (Form,  i) ;  or  morphia,  chloride  of  ammonium, 
and  tartar  emetic  (Form.  2)  may  be  used  until  the  expectoration 
becomes  free,  and  subsequently  carbonate  of  ammonium,  wit 
small  doses  of  morphia,  for  cough.     If  the  cough  is  not  very 


Io6  PULM"NAKV    DISEASES. 

troublesome,  we  may  give  chlorate  of  potassium  3  ss.  to  3  i. 
daily  in  divided  doses.  Tonics  may  be  required  until  resolu- 
tion is  complete. 

Chronic  bronchitis  is  often  dependent  upon  some  constitu- 
tional disease  or  diathesis,  which  should  receive  our  first  atten- 
tion. 

When  it  is  due  to  the  dartrous  diathesis,  arsenic,  in  doses  of 
«r,-.  fa-fa,  three  times  a  day,  is  specially  indicated. 

When  the  rheumatic  or  gouty  diathesis  is  present,  one  or 
more  of  the  following  remedies  may  be  given  from  three  to  five 
times  a  day  :  Acetate  of  potassium  gr.  xv.,  guaiacum  gr.  x.-xv., 
or  of  the  ammoniated  tincture  of  guaiacum  3ss.-3i.,  iodide 
of  potassium  gr.  v.-x.,  or  tincture  of  colchicum  TTIX.-XX. 

If  the  affection  originates  in  syphilis,  iodide  of  potassium  in 
full  doses,  with  bichloride  of  mercury,  will  have  the  best  effect. 

When  the  disease  is  of  simple  catarrhal  origin,  chlorate  of 
potassium  3  i.,  daily  in  divided  doses,  is  one  of  the  best  inter- 
nal remedies.  Preparations  of  squill,  senega,  yerba  santa,  and 
eucalyptus  are  sometimes  beneficial.  Vegetable  and  mineral 
tonics,  cod-liver  oil,  and  maltine  are  indicated,  if  the  patient  is 
debilitated. 

Persistent  counter-irritation  sometimes  aids  greatly  in  pro- 
moting a  cure. 

Locally. — Inhalations  similar  to  those  recommended  for  dis- 
eases of  the  throat  (Form.  34-38,  and  43-56)  are  beneficial. 
Cough  may  be  relieved  by  small  doses  of  morphia  and  carbo- 
nate of  ammonium  (Form.  5),  by  troches  of  morphia  (Form. 
2i).  and  often  by  sedative  inhalations  (Form.  36-40).  Great 
care  should  be  taken  on  the  part  of  the  patient  to  avoid  damp 
feet,  exposure  to  night  air,  cold  drafts,  overheated  atmospheres, 
and  the  inhalation  of  irritating  substances. 

CAPILLARY   BRONCHITIS. 

This  disease  consists  of  an  inflammation  of  the  mucous  mem- 
brane lining  the  capillary  bronchial  tubes.  It  usually  results 
from  extension  of  the  inflammation  affecting  the  larger  bronchi, 
and  it  affects  both  lungs  at  the  same  time. 

SYMPTOMS. 
The  principal  symptoms,  in  addition  to  those  found  in  acute 


CAPILLARY    BRONCHITIS.  IO7 

bronchitis,  are  severe  dyspnoea  with  lividity  of  the  surface  and 
great  prostration. 

SIGNS. 

The  principal  signs  are :  absence  of  dulness,  with  occasion- 
ally exaggerated  resonance  on  both  sides,  and  sibilant  or  sub- 
crepitant  rales  (Fig.  17,  page  67). 

INSPECTION. — The  respiratory  movements  are  rapid,  and  the 
countenance  shows  the  effects  of  imperfect  aeration  of  the 
blood. 

PALPATION  occasionally  yields  a  ronchial  fremitus,  due  to 
disease  in  the  larger  bronchial  tubes. 

PERCUSSION. — The  resonance  is  normal  or  slightly  exagger- 
ated over  the  lower  portions  of  the  chest.  This  exaggeration 
is  due  to  emphysema  of  a  portion  of  the  air-vesicles,  which 
results  from  complete  occlusion  of  some  of  the  smaller  tubes* 
with  collapse  of  their  terminal  vesicles,  and  consequent  dilata- 
tion of  the  surrounding  air-cells. 

AUSCULTATION  usually  furnishes  signs  of  general  bronchitis, 
and  in  addition  to  these,  early  in  the  course  of  the  affection, 
sibilant  rales  are  found  in  great  abundance,  which  a  little  later 
are  replaced  by  subcrepitant  rales.  These  subcrepitant  rales, 
when  numerous,  may  be  taken  as  a  positive  sign  of  capillary 
bronchitis,  but  a  few  are  frequently  heard  over  the  lower  por- 
tion of  the  chest,  simply  from  gravitation  of  fluids,  or  of  the 
products  of  inflammation  from  the  larger  bronchial  tubes. 

Occasionally  a  few  subcrepitant  rales  are  heard,  near  the  borders  of  the  lung,  even 
in  health. 

Subcrepitant  rales,  when  confined  to  the  base  or  to  the  apex 
of  one  lung,  usually  indicate  that  the  capillary  bronchitis  pro- 
ducing them  is  either  of  tuberculous  or  of  emphysematous 
origin. 

DIFFERENTIAL   DIAGNOSIS. 

Capillary  bronchitis  is  attended  by  signs  similar  to  some  of 
those  found  in  asthma,  pneumonia,  or  pulmonary  oedema. 

Asthma.— This  disease  may  be  distinguished  from  asthma  by 
the  history. 

Pneumonia. — Capillary  bronchitis  cannot  be  mistaken  for  the 
first  or  second  stage  of  lobar  pneumonia  if  we  bear  in  mind  that 
neither  of  these  stages  causes  many  sibilant  or  subcrepitant 
rales,  which  are  abundant  in  bronchitis :  and  that  both  stages 


Q*  PULMONARY   DISEASES. 

IOO 

are  attended  by  marked  dulness,  while  in  bronchitis  the  reso- 
nance is  either  unaltered  or  exaggerated.  From  the  third 
stage  of  lobar  pneumonia  this  disease  is  distinguished  oy  the 
signs  obtained  by  palpation,  percussion,  and  auscultation,  as 

follows :  * 

CAPILLARY  BRONCHITIS.  PNEUMONIA. 

Palpation. 
No  increase  in  the  vocal  fremitus.  Vocal  fremitus  increased. 

Percussion. 
No  dulness;  occasionally  exaggerated  More  or  less  dulness. 

resonance. 

Auscultation. 

Subcrepitant  rales  obtained  over  both  Subcrepitant  rales  confined  to  one  side, 

lungs  ;  these  rales  are  of  low  pitch.  over  the  affected  lung  ;    these  rales   are 

high  in  pitch. 

Lobular  Pneumonia.— -It  is  difficult  to  distinguish  between 
capillary  bronchitis  and  lobular  pneumonia,  with  which  it  often 
co-exists;  but  the  diagnosis  may  be  made  fairly  certain  by 
attention  to  the  following  points : 

CAPILLARY  BRONCHITIS.  LOBULAR  PNEUMONIA. 

Symptoms. 
Moderate  fever.     Moderately  accelera-  High  fever.     Very  rapid  respiration. 

ted  respiration. 

Percussion. 

No  dulness,  but  possibly  exaggerated  Limited  unchanging  spots  of   dulness 

resonance.  may  sometimes  be  detected,  though  as  the 

disease    usually   occurs    in    children,    in 
whom  dulness  is  difficult  to  detect,  this 
sign  is  liable  to  escape  observation. 
Auscultation. 

Multitudes  of  fine,  dry,  and  moist  rales  The  rales  are  limited  in  area,  unless  the 

over  every  part  of  the  chest.  two  diseases  co-exist.     Bronchial  breath- 

ing can  seldom  be  detected. 

.     Pulmonary   (Edema. — Capillary    bronchitis    is    distinguished 
from  pulmonary  oedema  by  the  following  symptoms  and  signs : 

CAPILLARY  BRONCHITIS.  PULMONARY  (EDEMA. 

History. 

Usually  shows    an    antecedent    acute  This    affection    usually   follows    some 

bronchitis  several  days  in  duration.  protracted  disease,  as  typhoid  fever,   or 

affections  of  the  heart  or  kidneys. 
Percussion. 

Resonance  normal  or  exaggerated.  Dulness  over  the  lower  part  of  both 

lungs. 

*  Signs  common  to  both  diseases  are  omitted  in  all  the  tables. 


PLASTIC  BRONCHITIS. 

Auscultation. 

Usually  numerous  rales  in   the  larger  Signs  of  general  bornchitis  areabsent. 

tubes. 

Phthisis. — This  disease  is  distinguished  from  phthisis  by  the 
history  of  the  case,  and  by  the  fact  that  the  subcrepitant  rales 
of  the  latter  affection  are  limited  to  a  smaller  portion  of  the 
chest,  which  is  usually  over  the  apex  of  one  lung. 

TREATMENT. 

Opiates  should  not  be  used  in  this  disease  excepting  in  very 
small  doses.  Early  in  the  disease,  muriate  of  ammonium  with 
syrup  of  ipecac  will  prove  beneficial ;  but  after  two  or  three 
days,  more  benefit  will  be  derived  from  carbonate  of  ammonium. 
Inhalations  of  steam,  or  steam  impregnated  with  sedative  reme- 
dies, will  have  a  soothing  effect  on  the  inflamed  bronchi 
(Form.  36-40).  Iodide  of  ammonium  in  small  and  often-re- 
peated doses  is  sometimes  a  most  efficient  remedy.  Strychnia 
gr.  ^V~rV  is  a  valuable  remedy  in  this  affection,  as  soon  as 
symptoms  of  exhaustion  supervene.  Alcoholics  should  be 
used  to  sustain  the  strength,  if  the  carbonate  of  ammonium 
does  not  seem  sufficient.  Cough  and  any  spasmodic  tendency 
should  be  relieved  by  camphor  or  by  small  doses  of  hydrocyanic 
acid. 

The  most  efficient  remedies  are  carbonate  of  ammonium  and 
strychnia,  with  large  jacket  poultices  kept  constantly  warm 
and  moist  and  covering  the  whole  chest.  The  diet  must  be 
nourishing. 

PLASTIC  BRONCHITIS. 

Synonyms. — Diphtheritic,  croupous,  or  exudative  bronchitis. 

Bronchitis  is  sometimes  complicated  by  exudation  of  fibri- 
nous  matter,  with  the  formation  of  false  membrane  or  plastic 
casts  in  the  smaller  air-tubes  and  their  ramifications.  The 
exudation  rarely  reaches  the  larger  bronchi,  and  it  is  said  never 
to  involve  the  upper  air-passages.  This  affection  may  be  acute 
or  chronic. 

SYMPTOMS. 

The  prominent  symptoms  are :  hacking  cough  with  scanty 
expectoration,  followed,  after  a  varying  interval  of  from  a  few 
hours  to  several  days,  by  a  sense  of  constriction  of  the  chest, 
and  dyspnoea  which  may  be  very  severe.  The  cough  gradu- 


PULMONARY   DISEASES. 

ally  increases  in  severity,  the  expectoration  becomes  more 
abundant,  and  perhaps  tinged  with  blood,  and  finally  small 
fragments  of  the  fibrinous  matter  or— after  severe  paroxysm  of 
cough— complete  casts  of  the  bronchi,  of  greater  or  less  extent. 

are  brought  up. 

SIGNS. 

The  physical  signs  are  those  of  ordinary  bronchitis,  super- 
added  to  which  we  have  the  signs  due  to  partial  or  complete 
obstruction  of  some  portion  of  the  bronchial  tree,  viz.,  weak- 
ness or  absence  of  the  respiratory  murmur,  with  dulness  where 
portions  of  the  lung  are  collapsed.  These  signs  may  lead 
us  into  an  erroneous  diagnosis  of  pleurisy  or  of  pneumonia. 
From  the  former  plastic  bronchitis  is  distinguished  by  absence 
of  catching  respiration,  pains,  and  friction  sounds;  by  the 
speedy  occurrence  of  dulness  with  loss  of  the  respiratory 
murmur  and  vocal  signs,  and  by  the  presence  of  signs  of 
bronchitis  in  other  parts  of  the  chest. 

We  distinguish  it  from  pneumonia  by  the  absence  of  bron- 
chial breathing  and  when  collapse  of  the  lung  occurs,  by  the 
sudden  accession  of  the  signs  of  consolidation.  The  differen- 
tiation from  ordinary  bronchitis  rests  entirely  upon  the  presence 
of  fibrinous  casts  in  the  sputa. 

TREATMENT. 

During  the  acute  attack  or  during  exacerbations  of  the 
chronic  disease,  the  treatment  should  be  essentially  the  same 
as  that  for  membranous  croup.  At  other  times,  the  iodide  of 
potassium  will  afford  some  relief.  The  general  health  must  be 
maintained  and  all  causes  of  cold  avoided. 


LECTURE   XI. 
DISEASES   OF   THE   LUNGS.— Continued. 

DILATATION    OF    THE    BRONCHIAL   TUBES. 

Synonyms. — Bronchiectasis,  or  bronchicatasis,  "  Knife-grind- 
er's rot,"  "  Filer's  phthisis,"  Cirrhosis  of  the  lungs.  It  is  some- 
times termed  fibroid  phthisis. 

This  disease  is  usually  associated  with  fibrous  induration  of 
the  lungs,  or  with  vesicular  emphysema.  It  is  generally  found 
over  the  middle  or  the  lower  portion  of  the  lung,  and  more 
frequently  on  the  right  than  on  the  left  side. 

SYMPTOMS. 

Patients  affected  with  this  disease  often  have  the  general 
appearance  of  phthisical  subjects.  The  principal  distinctive 
symptom  is  the  expectoration  of  an  opaque,  purulent,  and 
extremely  offensive  sputum,  which  is  very  abundant,  measur. 
ing  sometimes  from  one  to  three  pints  in  twenty-four  hours. 

SIGNS. 

The  principal  signs  are:  more  or  less  dulness,  and  a  harsh 
inspiratory  murmur  with  numerous  rales,  all  of  which  signs 
may  rapidly  change. 

INSPECTION  shows  imperfect  expansion  of  the  chest,  and 
prolonged,  labored  expiration,  with  more  or  less  fixity  of  the 
chest-walls,  and  depression  of  the  intercostal  spaces. 

The  signs  obtained  by  palpation,  percussion,  and  ausculta- 
tion vary  greatly  at  different  times,  according  to  the  amount 
of  fluid  in  the  tubes  or  cavities.  This  variation  in  the  signs  is 
of  itself  almost  diagnostic  of  the  disease. 

PALPATION.— The  ronchial  fremitus  may  or  may  not  be 
obtained.  The  vocal  fremitus  may  be  normal,  but  it  is  some- 
times increased,  at  other  times  diminished. 

PERCUSSION. — Some  dulness  is  usually  obtained  over  the 
affected  lung.  This  is  sometimes  removed  by  free  expectora- 
tion, and  it  may  then  be  followed  by  vesiculo-tympanitic  reso- 


H2  PULMONARY   DISEASES. 

nance.  It  is  apt  to  be  located  at  the  middle  or  the  lower  part 
of  the  lung,  and  it  is  most  common  on  the  right  side.  Light 
percussion  sometimes  elicits  dulness,  when  a  more  forcible 
stroke  would  produce  a  somewhat  tympanitic  sound. 

AUSCULTATION. — We  sometimes  find  the  respiratory  mur- 
mur suppressed  over  a  considerable  portion  of  the  lung,  while 
in  surrounding  portions  the  sounds  may  be  harsh  and  loud.  A 
few  moments  later,  free  expectoration  having  emptied  the  bron- 
chial tubes  and  the  cavities  communicating  with  them,  the 
respiration  may  become  broncho-vesicular  and  intense,  where 
at  first  it  could  not  be  heard.  The  respiratory  murmur  is 
often  associated  with  numerous  adventitious  sounds  of  every 
variety,  from  the  dry,  sibilant  rale  to  gurgles. 

The  vocal  resonance  is  subject  to  similar  changes,  and  from 
the  same  causes ;  that  is,  alterations  in  the  amount  of  fluid  in 
the  bronchial  tubes,  and  in  cavities  communicating  with  them. 

DIFFERENTIAL   DIAGNOSIS. 

Bronchiectasis  is  most  likely  to  be  mistaken  for plitJiis is,  from 
which  it  can  only  be  distinguished  by  attention  to  the  expec- 
toration, and  to  the  mutability  of  the  physical  signs.  The 
distinctive  features  between  the  two  may  be  seen  below. 

BRONCHIECTASIS.  PHTHISIS. 

Palpation* 

Fremitus  is  changeable.  Exaggerated  vocal  fremitus  not  univer- 

sal,   but  when  it  does  occur  the  sign  is 
usually  constant. 
Percussion. 

Dulness,  or  vesiculo-tympanitic   reso-  More  or   less  dulness,  which    remains 

nance,  often   changing  from  one  to  the         constant, 
other  during  the  examination. 

Auscultation. 

The  sounds  are  usually  found  over  the  The  signs  for  several  months  are  usu- 

lower  or  middle  portions  of  one  or  both  al  confined  to  the  upper  portion  of  one 
lungs,  and  they  change  rapidly  as  the  lung.  They  are  not  materially  altered  by 
result  of,  deep  inspiration  or  cough.  cough  or  by  deep  inspiration.  They  are 

confined   to   a   more  limited  space   than 
the  signs  of  dilatation  of  the  bronchi. 

TREATMENT. 

In  this  affection,  cod-liver  oil,  chloride  of  calcium,  and  vege- 
table tonics  are  generally  demanded.  Some  of  the  prepara- 
tions of  eucalyptus  globulus  or  grindelia  robusta  are  often 
beneficial,  as  are  also  copaiba,  turpentine,  senega,  and  squills. 


ASTHMA. 

Iodide  of  potassium  or  ammonium,  and  arsenic  are  often  useful. 
Inhalations  of  turpentine,  camphor,  iodine,  and  carbolic  acid 
are  frequently  useful  in  checking  or  altering  the  secretions. 
Counter-irritation  should  be  tried. 

ASTHMA. 

Asthma  is  a  spasmodic  affection  which,  by  causing  contrac- 
tion of  the  annular  muscular  fibres  of  the  bronchial  tubes, 
diminishes  the  calibre  of  these  tubes,  and  thus  obstructs  the 
entrance  of  air  to  the  air-cells.  This  disease  is  characterized 
by  sudden  paroxysms  of  dyspnoea,  with  stridulous  respiration. 
The  attack  usually  comes  on  during  the  latter  part  of  the  night, 
and  lasts  from  two  to  four  hours.  It  is  often  followed  by  the 
signs  of  bronchitis ;  these  in  simple  cases  usua.ly  disappear  in 
from  twelve  to  eighteen  hours.  Only  one  paroxysm  may 
occur,  or  the  attacks  may  succeed  each  other  night  after  night 
for  several  days,  or  even  for  months  together. 

Many  cases  of  spasmodic  night-cough  are  doubtless  due  to 
undeveloped  asthma. 

SYMPTOMS. 

As  already  intimated,  paroxysmal  dyspnoea,  occurring  at 
night,  is  the  leading  symptom. 

SIGNS. 

The  principal  signs  are  labored  and  wheezing  respiration, 
attended  with  numerous  sonorous  and  sibilant  rales,  which 
may  be  heard,  and  often  may  be  felt,  over  the  whole  chest. 

INSPECTION. — Respiration  is  labored,  especially  during  inspi- 
ration. 

PALPATION,  MENSURATION,  and  PERCUSSION  yield  no  dis- 
tinctive signs.  The  resonance  may  be  normal  or  slightly 
exaggerated. 

AUSCULTATION. — By  auscultation,  we  obtain  jerking  or  cog- 
wheel respiration,  with  a  great  variety  of  sonorous  and  sibilant 
rales.  The  respiratory  murmur  is  usually  harsh  and  more  or 
less  tubular,  the  vesicular  element  being  suppressed.  \rocal 
resonance  is  normal. 

DIFFERENTIAL   DIAGNOSIS. 

During  the  paroxysm,  asthma  may  be  mistaken  for  cardiac 
dyspnoea  or  capillary  bronchitis.  From  the  former  it  may  be 


PULMONARY   DISEASES. 
114 

distinguished  by  the  history,  by  the  absence  of  cardiac  signs, 
and  by  the  presence  of  a  great  number  of  sonorous  and  sibilant 

rales. 

Capillary  bronchitis  differs  from  asthma  in  its  history,  and  in 
some  of  the  signs  obtained  by  inspection  and  by  auscultation, 
as  shown  in  the  following  table : 

ASTHMA.  CAPILLARY  BRONCHITIS. 

History. 

A  sudden  attack,  with  usually  a  his-  Dyspnoea  comes  on  gradually,  usually 

tory  of  former  paroxysms.     Febrile  symp-        preceded   by  acute  or  subacute  bronchi- 
toms  not  marked.  tis.     Febrile  symptoms  pronounced. 

Inspection. 

Respiration   labored,    but   not  greatly  Respiration  not  only  labored,  but  also 

accelerated.  rapid. 

Auscultation. 

Sonorous  and  sibilant  rales,  usually  fol-  Mucous  rales  likely  to  precede  the  sibi- 

lowed  by  large  and  small  mucous  rales.  lant  rales,  and  the  sibilant  to  be  followed 

by  the  subcrepitant. 

After  the  paroxysm,  the  signs  of  asthma  are  the  same  as 
those  of  bronchitis ;  but  they  last  only  a  few  hours.  Asthmatic 
symptoms  often  occur  during  the  progress  of  pulmonary  emphy- 
sema ;  but  these  two  diseases  may  be  easily  distinguished  from 
each  other  by  the  history.  In  emphysema,  as  in  cardiac  disease, 
the  dyspnoea  is  permanent,  and  it  is  aggravated  by  exercise  ; 
while  in  asthma  the  dyspnoea  usually  comes  on  during  the 
hours  of  rest. 

TREATMENT. 

During  the  paroxysm,  the  most  effectual  internal  treatment 
consists  of  morphia  and  chloral  (Form.  3)  repeated  every  half- 
hour  or  every  hour  until  relief  is  obtained.  This  may  be  com- 
bined with  half  a  drachm  of  fl.  ext.  of  quebracho  or  with  the 
fl.  ext.  of  grindelia  robusta,  either  of  which  is  sometimes  benefi- 
cial. Two  or  three  cups  of  strong  hot  coffee  will  frequently 
ward  off  an  attack,  if  taken  when  the  first  symptoms  are 
noticed.  The  severity  of  the  paroxysms  may  be  greatly  modified 
by  small  doses  of  belladonna,  hyoscyamus,  bromide  of  potassium, 
or  camphor.  Fuming  inhalations  of  arsenic  or  nitrate  of 
potassium,  alone  or  combined  with  other  antispasmodics,  such 
as  stramonium,  hyoscyamus  or  tobacco  give  speedy  relief  in 
some  cases  (Form.  85).  Galvanizing  the  pneumogastric  nerve, 
with  the  positive  pole  beneath  the  mastoid  process,  and  the 


PULMONARY   EMPHYSEMA.  nc 

negative  pole  on  the  epigastrium,  will  promptly  relieve  some 
cases. 

If  bronchitis  or  pneumonia  supervenes,  it  should  receive 
similar  treatment  to  that  recommended  when  it  occurs  as  a 
primary  disease.  The  general  treatment  of  asthmatic  patients 
should  be  supporting.  Between  the  paroxysms  an  effort  should 
be  made  to  prevent  their  recurrence.  The  most  efficacious 
remedy  for  this  purpose  is  iodide  of  potassium,  but  in  some 
cases  iodide  of  ammonium,  grindelia,  eucalyptus,  arsenic,  or 
guaiacum  will  be  found  useful.  It  should  be  remembered  that 
asthma  may  result  from  the  rheumatic  or  dartrous  diathesis 
and  that  it  is  often  caused  by  bronchitis  or  emphysema,  as  well 
as  by  purely  nervous  affections.  The  treatment  must  there- 
fore vary  according  to  the  conditions  of  each  case. 

All  medicines  may  fail,  and  then  a  change  of  climate  should 
be  tried.  The  climate  of  Colorado  is  perhaps  the  most  fre- 
quently beneficial  to  these  patients,  but  very  slight  changes 
may  be  sufficient  to  prevent  a  recurrence  of  the  attacks  ;  there- 
fore "  each  patient  must  be  a  law  unto  himself"  in  this  regard. 
By  repeated  trials,  the  majority  of  cases  will  find  some  locality 
where  they  will  be  free  from  asthmatic  attacks. 

PULMONARY  EMPHYSEMA. 

Emphysema  consists  of  dilatation  of  the  air-vesicles,  with 
occasionally  uniform  dilatation  of  the  bronchial  tubes.  In  the 
hypertrophous  form,  which  is  most  common,  the  volume  of  the 
lungs  is  increased.  In  a  rarer  variety  of  the  affection  occurring 
only  in  old  people,  known  as  senile  or  atropltous  emphysema, 
some  of  the  air-cells  are  distended  and  others  are  destroyed, 
without  any  increase  in  the  volume  of  the  lung. 

Emphysema  is  one  of  the  bilateral  diseases.  In  exceptional 
instances,  however,  it  may  be  confined  to  one  lung  or  to  a 

single  lobe  of  one  lung. 

SYMPTOMS. 

The  prominent  symptoms  are  constant  dyspnoea,  associated 
often  with  the  symptoms  of  bronchitis,  or  asthma,  or  of  both. 

SIGNS. 

The  prominent  signs  are  :  lifting  of  the  sternum  in  inspira- 
tion;  "barrel-shaped"  chest;  vesiculo-tympanitic  resonance, 
and  prolonged  expiration. 


6  PULMONARY   DISEASES. 

INSPECTION.— In  well  marked  cases,  the  countenance  is 
dusky,  the  eyes  prominent,  the  nostrils  dilated,  and  the  sterno- 
cleido-mastoid  muscles  stand  out  like  whip-cords  in  their  efforts 
to  aid  in  respiration.  The  shoulders  are  elevated  and  drawn 
forward  ;  the  neck  is  apparently  shortened  and  the  individual 
seems  to  stoop,  which  gives  him  the  appearance  of  old  age. 
The  margins  of  the  scapulae  sometimes  stand  out  like  wings, 
and  there  is  an  increase  in  the  antero-posterior  diameter  of  the 
chest,  giving  the  rounded  appearance  termed  barrel-shaped. 
During  inspiration,  there  is  no  expansive  movement  of  the 
upper  ribs,  but  they  are  elevated  as  if  the  chest- walls  were  com- 
posed of  a  single  bone.  In  marked  cases  of  this  disease,  with 
inspiration,  there  is  falling-in  of  the  soft  parts  of  the  chest 
above  the  clavicles  and  sternum ;  the  intercostal  spaces  at  the 
upper  part  of  the  chest  are  wider  and  more  distinct  than  usual ; 
and  there  is  retraction  instead  of  dilatation  of  the  false  ribs 
during  inspiration.  Early  in  the  disease,  these  signs  are  not 
present. 

In  a  few  instances  among  old  people,  in  cases  known  as  atrophous  emphysema,  the 
intercellular  septa  are  destroyed  by  atrophy  and  the  vesicles  coalesce.  The  volume  of 
the  lung  is  thereby  more  or  less  diminished,  so  that  the  disease  causes  no  distention  of 
the  chest.  In  such  cases,  no  signs  would  be  obtained  on  inspection,  except  perhaps 
retraction  and  an  increased  obliquity  of  the  lower  ribs,  with  considerable  diminution  of 
the  space  between  them  and  the  crest  of  the  ilium 

PALPATION. — The  apex  beat  of  the  heart  is  frequently  found 
below  its  normal  position,  and  nearer  the  median  line. 

The  vocal  fremitus  may  be  exaggerated,  diminished,  or  normal. 

MENSURATION  shows  us  the  exact  increase  in  the  antero- 
posterior  diameter  of  the  chest,  and  the  deficient  expansive 
movement  of  inspiration. 

PERCUSSION  yields  vesiculo-tympanitic  resonance,  which  is 
usually  most  marked  over  the  upper  portion  of  the  left  lung. 
This  is  more  intense,  and  according  to  Dr.  Flint,  it  is  higher 
in  pitch  than  the  normal  resonance.  Percussion  over  the 
praecordia  may  show  the  area  of  superficial  cardiac  dulness  to 
be  diminished,  or  the  entire  region  may  yield  pulmonary 
resonance,  due  to  the  expansion  of  the  border  of  the  left  lung, 
so  that  it  completely  covers  the  heart. 

Deep  inspiration  or  forced  expiration  will  not  materially 
affect  the  pulmonary  resonance,  as  it  would  in  health. 


PULMONARY   EMPHYSEMA.  u- 

AUSCULTATION.— The  vesicular  murmur  is  impaired,  the 
inspiratory  sound  being  deferred,  and  consequently  shortened 
and  the  expiratory  sound  being  prolonged,  so  that  the  ratio 
between  the  two  may  be  reversed,  making  the  expiratory 
sound  equal  in  length  to  the  inspiratory,  or  even  three  or  four 
times  as  long.  Both  sounds  are  low  in  pitch.  A  peculiar  dry, 
crackling  sound,  closely  resembling  fine  pleuritic  friction,  is 
often  heard  just  at  the  end  of  inspiration  or  at  the  beginning  of 
expiration.  It  is  produced  in  the  walls  of  the  air-vesicles. 
Harsh,  blowing  sounds  from  the  bronchial  tubes  are  often 
present.  . 

Exceptional. — In  rare  cases,  especially  in  the  aged,  the  inspiratory  and  the  expira- 
tory sounds  are  of  equal  duration,  exaggerated  in  intensity,  harsh  and  tubular  in 
quality,  and  high  in  pitch.  This  is  probably  due  to  atrophy  of  a  portion  of  the  lung 

tissue. 

The  vocal  resonance  may  be  either  increased  or  diminished. 

The  heart-sounds  are  usually  feeble,  and  displaced  down- 
ward and  inward,  in  consequence  of  the  intervention  of  the 
emphysematous  lung  between  this  organ  and  the  surface  of  the 
chest.  The  cardiac  sounds  and  impulse  are  often  abnormally 
distinct  in  the  epigastric  region,  due  to  displacement  of  the 
heart  and  to  dilatation  of  the  right  ventricle.  Dilatation  of 
the  ventricle  may  cause  tricuspid  regurgitation  with  a  valvular 
murmur. 

DIFFERENTIAL   DIAGNOSIS. 

The  diseases  likely  to  be  mistaken  for  emphysema  are :  dilata- 
tion of  the  lung  from  acute  tuberculosis ;  and  pneumothorax. 
When  confined  to  one  lung,  emphysema  may  be  mistaken  for 
any  of  the  diseases  which  usually  cause  feeble  respiration.  In 
such  cases,  the  normal  murmur  of  the  sound  side  is  liable  to  be 
mistaken  for  exaggerated  respiration,  and  the  feeble  murmur  of 
the  emphysematous  lung  for  the  normal  sounds.  Error  may 
be  avoided  by  remembering  that  the  feeble  respiratory  murmur 
of  emphysema  is  characterized  by  prolonged  expiration,  and  that 
the  resonance  over  the  affected  lung  is  more  marked  than  that 
of  the  sound  side :  while  in  nearly  all  diseases  causing  feeble 
respiration,  from  obstruction  in  the  air-passages  or  from  inter- 
ference with  the  free  expansion  of  the  lung,  the  expiratory 
sound  is  shorter  than  the  inspiratory,  and  the  resonance  is  less 
intense  than  on  the  sound  side.  Emphysema  of  one  lung,  or  of 


g  PULMONARY  DISEASES. 

a  single  lobe  of  one  lung,  is  a  rare  affection ;  but  when  it  does 
occur,  great  care  is  necessary  to  avoid  errors  in  diagnosis. 

fttcumot/iorax.—This  disease,  when  bilateral,  is  differentiated 
from  pneumothorax  by  th.e  signs  furnished  upon  inspection, 
percussion,  and  auscultation,  as  seen  in  the  following  table  :* 

EMPHYSEMA.  PNEUMOTHORAX. 

Inspection. 

Prominence  of  both  sides,  especially  of  Uniform   distention   of    one    side,    no 

the  antero-superior  portion  of  the  chest,         sinking-in  of  the  soft  parts  during  inspi- 
with  falling-in  of  the  soft  parts  during  in-        ration. 

spiration. 

Pemtssion. 

Vesiculo-tympanitic  resonance  on  both  Tympanitic  resonance  tm  one  side  only. 

sides. 

Auscultation. 

The   respiratory  murmur   is    vesicular  The   respiratory   murmur   is  feeble  or 

in  quality,  and  expiration  is  prolonged.  suppressed,  or  it  may  be  amphoric. 

Emphysema  of  a  single  lung  is  distinguished  from  pneumo- 
thorax by  the  following  signs : 

EMPHYSEMA  OF  ONE  LUNG.  PNEUMOTHORAX. 

Percussion. 

Vesiculo-tympanitic  resonance.  Tympanitic  resonance  more  or  less  in- 

tense,   with    absence    of     the    vesicular 
quality. 
Auscultation. 

The  inspiratory  murmur  is  delayed,  the  The  vesicular  murmur  feeble  or  absent; 

expiratory  sound  prolonged,  but,  if   heard,  regular   in    rhythm.     The 

respiration  may  be  amphoric. 

Acute  Tuberculosis. — Dr.  Thompson  states  that  in  acute 
tuberculosis  as  numbers  of  the  air-vesicles  become  filled  with  the 
tubercular  deposit,  the  adjoining  cells  become  distended  so 
as  to  cause  physical  signs,  especially  in  front,  almost  identical 
with  those  of  emphysema.  The  distinctive  features  of  the  two 
diseases  may  be  seen  in  the  following  table : 

EMPHYSEMA.  ACUTE  TUBERCULOSIS. 

History. 

Affection  gradually  developed.  Comparatively  rapid  accession. 

«  Symptoms. 

Constitutional  symptoms  often  slight.  Constitutional     symptoms     similar     to 

those  of  typhoid  fever. 
Inspection. 

Cyanosis;     labored     expiration;     chest  Pallor;    respirations   rapid  but  not   la- 

enlarged,  bored;  chest  not  enlarged. 

*  In  this,  as  in  other  tables,  only  the  differential  signs  are  given,  those  which  are 
alike  being  omitted. 


PULMONARY   EMPHYSEMA.  ,  IQ 

Percussion. 

Vesiculo-tympanitic  resonance  more  or  Vesiculo-tympanitic  resonance  in  front, 

less  marked  over  whole  chest.  but  actual  dulness  behind. 

Auscultation, 

Expiratory  murmur  prolonged  and  low  Expiratory    murmur    not    much     pro- 

in  pitch.  longed  and  higher  in  pitch  than  normal. 

Fibrosis  or  Fibroid  Disease  of  both  lungs,  produces  some  signs 
which  are  liable  to  cause  it  to  be  mistaken  for  emphysema. 
The  distinction  may  be  readily  made  from  the  following  signs : 

EMPHYSEMA.  FIBROID  DISEASE  OF  BOTH  LUNGS. 

Inspection. 

Fixity  of  the  chest  with  bulging,  except  Fixity  of  the  chest  with  flattening, 

in  the  atrophous  form. 

Palpation. 
Vocal  fremitus  usually  diminished.  Vocal  fremitus  markedly  increased. 

Percussion. 

Vesiculo-tympanitic  resonance.  Usually  dulness,  but  occasionally  reso- 

nance approaching  tympanitic  in  quality. 

Heart  covered  by  lung  tissue,  as  shown  Heart    uncovered,    causing    increased 

by  resonance.  area  of  superficial  dulness. 

Auscultation. 

Low-pitched  respiratory  sounds,  though  Absence  of  respiratory  murmur  at  times, 

sometimes   considerable   harshness    from         In  other  instances,  rude  respiration, 
affection  of  the  bronchi. 

TREATMENT. 

As  the  changes  in  the  lung  tissue  in  this  disease  are  due 
rather  to  general  malnutrition  than  to  local  causes,  our  first  aim 
in  treatment  must  be  to  improve  the  general  condition.  The 
remedies  of  most  service  for  this  purpose  are  tincture  of  iron, 
cod-liver  oil,  and  occasionally  small  doses  of  quinine. 

Chronic  bronchitis  usually  co-exists,  and  should  receive  treat. 
ment  similar  to  that  mentioned  when  considering  the  latter 
disease.  Iodide  of  potassium  is  the  most  serviceable  single 
remedy  in  this  disease.  It  should  be  given  in  doses  of  gr.  v.- 
xx.,  three  or  four  times  a  day  for  a  long  time.  Arsenic  long 
continued  has  been  found  beneficial.  Asthmatic  symptoms 
are  to  be  treated  as  spasmodic  asthma.  Cough  may  require 
anodynes.  Expiration  into  rarefied  air  has  benefited  some  cases. 

The  patient  must  avoid  all  causes  of  cold  or  asthmatic 
attacks,  and  should  live  if  possible  in  a  climate  where  he  will 
be  most  free  from  dyspnoea.  High  altitudes  are  not  to  be 
recommended  for  these  cases. 


LECTURE  XII. 
DISEASES  OF  THE  LUNGS.— Continued. 

PNEUMONIA. 

Synonyms.— Peripneumonia,  Peripneumonia  Vera.  Popu- 
larly known  as  lung  fever  or  inflammation  of  the  lungs. 

There  are  two  recognized  varieties  of  this  disease,  one 
known  as  lobar  pneumonia,  in  which  the  greater  part  or  the 
whole  of  one  lobe,  or  the  whole  lung,  is  affected  ;  and  the  other 
as  lobular  pneumonia,  in  which  the  inflammation  is  confined  to 
smaller  portions  of  the  lungs,  consisting  of  a  single  lobule,  or  of 
groups  of  lobules,  scattered  through  the  lungs.  According  to 
the  origin  and  character  of  the  disease,  its  various  manifesta- 
tions have  also  been  termed  primary  or  secondary  pneumonia ; 
or  bilious,  gastric,  typhoid,  latent  or  walking,  intermittent, 
hypostatic,  tubercular,  scrofulous,  rheumatic,  gouty,  puerperal, 
or  metastatic  pneumonia ;  but  these  varieties,  if  they  may  be  so 
called,  require  no  special  description.  Though  different  cases 
vary  more  or  less  in  their  origin  and  in  their  anatomical  charac- 
ters, as  well  as  in  a  few  of  their  clinical  features,  it  would  only 
confuse  us  to  attempt  to  differentiate  between  them  by  their 
physical  signs.  I  shall  therefore  describe  only  lobar  and 
lobular  pneumonia,  the  signs  of  which  include  those  of  the  other, 
so-called  varieties.  But  I  will  mention,  under  their  respective 
headings,  special  forms  of  the  disease,  and  the  signs  which  are 
believed  to  be  of  value  in  enabling  us  to  distinguish  between 
them. 

LOBAR  PNEUMONIA. 

Synonyms. — Acute  pneumonia ;  Croupous  pneumonia  :  Acute 
sthenic  pneumonia. 

Lobar  pneumonia  consists  of  an  inflammation  of  the  vesic- 
ular structure  of  the  lungs  with  accumulation  of  inflammatory 
exudation  in  the  air-cells,  whereby  they  are  filled  and  rendered 
impervious  to  air. 


LOBAR    PNEUMONIA. 


121 


SYMPTOMS. 

The  affection  comes  on  suddenly  with  rigors,  and  fever 
which  attains  great  intensity  in  a  few  hours  and  as  suddenly 
subsides  between  the  fifth  and  the  tenth  days.  It  is  attended 
with  pain  in  the  side,  dyspnoea,  cough,  clear  tenacious  and 
subsequently  rusty  sputa;  with  great  prostration  and  often  with 
delirium. 

SIGNS. 

The  essential  signs  in  the  order  of  their  occurrence  are ; 
diminished  movement  of  the  side,  some  dulness  and  crepitant 
rales,  followed  by  marked  dulness,  bronchial  breathing  and 


Normal  signs. 


Bronchial  breathing  (_ 
and  bronchophony.       j 


Subcrepitant  rales. 


Fig.  23. 

The  upper  lobe  indicates  healthy  lung  tissue.  The  middle  lobe  represents  the  second 
stage  of  pneumonia  (red  hepatization)  and  the  lower  lobe  illustrates  the  third  stage 
(gray  hepatization). 

bronchophony.     These  signs  are  succeeded  in  favorable  cases 
by  subcrepitant  rales  and  a  gradual  return  of  the  healthy  signs 

(Fig-  23). 

For  the  sake  of  convenience  in  description,  the  disease  is 
divided  into  three  stages,  each  possessing  signs  more  or  less 
characteristic.  The  first  stage  begins  with  the  inception  of 
the  disease,  and  continues  until  the  air-vesicles  are  completely 
filled.  At  this  point  the  second  stage  begins,  and  it  continues 


PULMONARY   DISEASES. 
I  22 

throughout  the  period  of  consolidation,  which  is  also  known,  as 
the  stage  of  red  hepatization.     The  third  stage,  or  the  stage  of 
gray  hepatization  commences  with  the  beginning  of  resolution 
and  continues  until  convalescence  is  complete. 
SigJis  of  the  First  Stage. 

INSPECTION.— The  movements  oi  the  chest  are  somewhat 
diminished  over  the  affected  organ. 

PALPATION  in  the  early  part  of  this  stage  yields  only 
negative  results ;  later,  the  vocal  fremitus  is  increased. 

PERCUSSION  early  in  this  stage  elicits  slight  dulness,  which 
gradually  increases  as  the  stage  advances. 
"  AUSCULTATION.— While  there  is  congestion  only,  before 
inflammation  has  become  fairly  established,  the  respiratory 
murmur  is  feeble  ;  but  soon  as  exudation  takes  place,  dry  crepi- 
tant  rales  occur  in  great  numbers  with  inspiration.  When 
these  riles  are  well  marked  and  persistent,  they  may  be  regarded 
as  pathognomonic. 

When  the  inflammation  is  associated  with  inflammatory  rheumatism,  the  crepitant 
rale  does  not  occur.  Subcrepitant  rales  are  sometimes  associated  with  the  crepitant, 
but  the  latter  greatly  predominate. 

As  consolidation  progresses,  the  respiration  becomes  broncho- 
vesicular  and  finally  bronchial. 

Signs  of  the  Second  Stage. 

INSPECTION  AND  PALPATION. — The  movements  are  still 
found  to  be  deficient  on  the  affected  side,  and  exaggerated  on 
the  opposite  side.  Vocal  fremitus  exaggerated. 

Exceptional. — Consolidation  in  rare  instances  diminishes  the  vocal  fremitus,  in 
consequence  of  complete  occlusion  of  the  bronchial  tubes. 

PERCUSSION. — There  is  perfect  dulness  over  the  affected  lobe, 
with  exaggerated  resonance  over  the  healthy  portions  of  the 
lung.  The  line  separating  dulness  from  vesicular  resonance 
usually  corresponds  to  the  position  of  the  interlobular  fissure, 
and  it  is  not  altered  by  changes  in  the  position  of  the  patient. 

Exceptional. — In  rare  cases  the  density  of  the  lung  is  so  great  that  the  percussion 
sound  caused  by  vibration  of  air  in  the  bronchial  tubes  is  transmitted  to  the  surface 
with  such  peculiar  distinctness  as  to  justify  the  appellation  of  tubular  resonance. 

In  some  instances  of  extreme  consolidation,  the  resonance  seems  almost  amphoric. 


LOBAR   PNEUMONIA.  I2- 

In  such  cases  the  solid  sounds  would  of  necessity  be  mistaken  for  hollow  sounds,  were 
it  not  for  their  pitch,  which  is  always  high  instead  of  being  low,  like  the  proper  resonance 
of  cavities.  In  rare  cases,  flatness  is  found  instead  of  dulness. 

AUSCULTATION. — There  are  no  crepitant  rales,  but  in  their 
place,  we  find  bronchial  or  broncho-vesicular  respiration,  vary- 
ing in  degree  with  the  amount  of  consolidation.  There  is  also 
co-existing  bronchophony  and  whispering  bronchophony.  A 
few  moist  and  dry  bronchial  rales  are  liable  to  be  heard  in  this 
stage. 

Exceptional. — In  rare  cases  a  few  crepitant  rales  may  be  heard  in  this  stage.  In 
other  instances,  the  bronchial  tubes  of  larger  size  may  be  filled  by  the  inflammatory 
lymph  so  that  the  vocal  resonance  is  diminished  instead  of  being  intensified,  and  all  respi- 
ratory sounds  may  be  suppressed. 

Signs  of  the  Third  Stage. 

In  the  early  part  of  the  third  stage,  the  signs  are  the  same 
as  in  the  second  stage,  with  the  addition  of  a  few  subcrepitant 
rales.  As  the  stage  advances,  the  vocal  fremitus  becomes 
gradually  lessened,  dulness  diminishes  over  the  inflamed 
portion  of  the  lung,  and,  upon  auscultation,  bronchial  breathing 
slowly  gives  place  to  broncho-vesicular  breathing,  and  this 
finally  to  the  normal  respiratory  murmur.  Subcrepitant  rales 
appear  early  in  this  stage,  and  continue,  often  associated  with 
mucous  rales  in  the  larger  bronchi,  until  resolution  is  nearly 
complete. 

The  crepitant  rale  also  occasionally  reappears;  it  is  then 
known  as  the  "  crepitant  rale  redux." 

Bronchophony,  which  was  present  in  the  second  stage,  grad- 
ually gives  place  to  exaggerated  vocal  resonance,  and  this,  in 
turn,  to  the  normal  sounds  of  the  voice. 

DIFFERENTIAL   DIAGNOSIS. 

This  disease  is  to  be  diagnosticated  from  pleurodynia,  inter- 
costal neuralgia,  pleurisy,  pulmonary  oedema',  collapse  of  the 
air-vesicles,  hydrothorax,  phthisis,  and  bronchitis. 

It  is  not  likely  to  be  mistaken  for  pleurodynia  or  intercostal 
neuralgia  by  any  one  familiar  with  physical  diagnosis,  as  the 
latter  diseases  yield  no  signs  excepting  those  due  to  the  pain. 

Pleurisy,— From  pleurisy  it  is  distinguished  by  the  following 
features : 


124 


PULMONARY   DISEASES. 


PNEUMONIA. 
First  Stage. 

Moderate  dulness  with  feeble  respira- 
tion. Numerous  crepitant  rales  and  ex- 
aggerated vocal  resonance. 


Second  Stage. 

The  vocal  fremitus  exaggerated.  Dul- 
ness marked  with  no  change  of  the  upper 
limit  by  changes  in  the  position  of  the 
patient. 

Bronchial  respiration  and  bronchoph- 
ony. 

Third  Stage. 

Subcrepilant  rales  are  found  in  addition 
to  the  harsh  respiration,  exaggerated  res- 
piratory and  vocal  signs,  and  dulness,  of 
the  second  stage. 


PLEURISY. 
First  Stage. 

Resonance  normal.  Respiratory  mur- 
mur feeble  or  absent.  Ordinarily  graz- 
ing or  creaking  friction  sounds,  but  oc- 
casionally transitory  crepitating  friction 
murmurs,  few  in  numbers  as  compared 
with  crepitant  rales.  These  are  usually 
heard  during  three  or  four  inspirations, 
and  then  disappear  to  return  again  in  a 
few  moments. 

Second  Stage. 

Vocal  fremitus  absent.  Flatness  in- 
stead of  dulness.  The  line  of  flatness 
changes  with  changes  in  the  patient's 
position. 

Usually  absence  of  all  respiratory  and 
vocal  sounds. 

Third  Stage. 

Friction  fremitus  and  murmur ;  ab- 
sence of  rales.  Respiratory  and  vocal 
signs  nearly  or  quite  normal.  More  or 
less  dulness. 


Pulmonary  (Edema  is  only  liable  to  be  mistaken  for  the  first 
and  third  stages  of  pneumonia.  The  diagnosis  is  generally 
easily  made  if  we  recollect  that  cedema  is  a  bilateral  disease 
and  that  pneumonia  is  usually  unilateral.  In  cedema  the  dul- 
ness is  slight,  and  it  occurs  on  both  sides.  In  pneumonia  it  is 
marked  in  the  third  stage,  and  is  found  only  on  one  side. 

Crepitant  rales  are  few  in  oedema  and  are  nearly  always 
associated  with  moist  rales.  In  the  first  stage  of  pneumonia 
crepitant  rales  are  very  abundant,  and  they  are  seldom  asso- 
ciated with  moist  sounds. 

Subcrepitant  rales  in  cedema  are  heard  upon  both  sides  and 
are  not  high  in  pitch  or  metallic  in  quality.  In  pneumonia 
they  are  found  only  on  one  side,  and  they  are  high  in  pitch  and 
are  usually  metallic. 

(Edema  usually  follows  some  protracted  disease,  as,  for  ex- 
ample, typhoid  fever.  Pneumonia  is  generally  a  primary 
affection. 

Pulmonary  Collapse  or  Atelectasis,  is  distinguished  from  pneu- 
monia by  the  history  and  by  the  ensemble  of  the  physical  signs, 


LOBAR   PNEUMONIA.  I2- 

rather  than  by  any  pathognomonic  characteristics.     The  points 
of  distinction  are  shown  in  the  following  table : 

PNEUMONIA.  PULMONARY  COLLAPSE. 

History. 

Usually  a  primary  affection  involving  Generally  a  sequel  of  bronchitis,  often 

only  one  lung.  involving  both  lungs. 

Percussion. 
Marked  dulness.  Moderate  dulness,  frequently  vesiculo- 

tympanitic  resonance  in  the  vicinity. 
Auscultation. 

In  the  first  and  third  stages  crepitant  Few,  if  any  crepitant  or  subcrepitant 

and  subcrepitant  rales.  rales. 

Second  stage  bronchial  breathing,  with  Bronchial    breathing     over     collapsed 

exaggerated  respiration  over  healthy  lung.         lung;  prolonged  emphysematous  expira- 
tion near  it. 

Rales  and  other  abnormal  signs  usually  Rales    due    to   bronchitis    over    both 

confined  to  one  lung  or  one  lobe  of  that  lungs.  Other  signs  due  to  collapse  more 
lung-  apt  to  affect  both  lungs  and  not  likely  to 

involve  an  entire  lobe  of  either. 

Hydrothorax. — The  distinction  between  pneumonia  and  hy- 
drothorax  is  shown  below  : 

PNEUMONIA.  HYDROTHORAX. 

Unilateral  dulness,  and  the  respiratory  Bilateral  flatness,  with  absence  of  respi- 

and  vocal  signs  of  consolidation.  ratory  and  vocal  signs. 

PhtJiisis. — To  distinguish  pneumonia  from  phthisis,  a  knowl- 
edge of  the  history  and  the  symptoms  is  frequently  essential. 
Many  physicians  consider  a  case  in  which  the  signs  of  pneu- 
monia have  continued  for  more  than  four  or  five  weeks  to  be 
consumption ;  but  this  rule  will  not  always  hold  good.  The 
distinctive  features  between  these  two  diseases,  as  they  ordi- 
narily present  themselves,  may  be  seen  in  the  following  table : 

PNEUMONIA.  PHTHISIS. 

An  acute  affection    usually   involving  A  protracted  disease  coming  on  insidi- 

the  greater  portion  of  the  lower  lobe  of  ously,  nearly  always  beginning  at  the 
one  lung  and  giving  rise  to  the  signs  of  apex  of  the  lung,  and  at  first  involving 
consolidation.  only  a  limited  amount  of  tissue  ;  giving 

rise,  first,  to  the  signs  of  slight  and  sub- 
sequently to  those  of  greater  consolida- 
tion. 

Phthisis,  following  upon  pneumonia,  will  be  distinguished  from 
prolonged  cases  of  the  simple  inflammation  by  the  history  and 
by  the  physical  signs  obtained  on  repeated  examinations. 

Bronchitis  cannot  be  mistaken  for  the  early  stages  of  pneu- 


J26  PULMONARY    DISEASES. 

monia  by  any  one  familiar  with  physical  diagnosis.  The  rales 
of  the  resolving  stage  of  pneumonia  might  be  mistaken  for 
those  of  bronchitis ;  but  there  is  no  danger  of  error  if  we 
remember  that  the  latter  is  a  bilateral  disease  and  causes  little 
or  no  dulness  on  percussion,  and  that,  when  dulness  does  occur, 
it  disappears  after  cough  and  free  expectoration. 

TREATMENT. 

Within  the  first  ten  or  fifteen  hours  from  the  inception  of  the 
attack,  a  blister  will  sometimes  prevent  further  development  of 
the  inflammatory  process ;  but  patients  are  seldom  seen  by  a 
physician  early  enough  to  allow  of  the  use  of  this  agent. 

For  the  first  two  or  three  days,  small  doses  of  aconite  or 
veratrum  viride  are  very  useful.  They  should  be  given  often, 
in  just  sufficient  doses  to  keep  the  pulse  nearly  down  to  its 
natural  rate ;  but  they  must  not  be  continued  after  the  third 
day.  During  the  same  period  fluid  ext.  of  ergot  should  be 
given  in  doses  of  3  ss.  every  three  or  four  hours. 

After  the  second  day  of  the  disease,  quinine  in  doses  of  three 
to  five  grains  every  three  to  five  hours  is  the  best  anti-pyretic. 

During  the  active  stage  of  inflammation,  large,  hot,  jacket 
poultices,  enveloping  the  whole  side,  are  beneficial  if  they  can 
be  kept  constantly  and  thoroughly  applied  ;  otherwise  they  do 
harm.  When  poultices  cannot  be  managed  satisfactorily,  an 
oil-silk  jacket  should  be  employed  with  warm  clothing.  From 
the  very  first,  the  patient  should  keep  perfectly  quiet,  neither 
moving  nor  speaking  excepting  when  absolutely  necessary. 

Very  small  doses  of  opium  or  moderate  doses  of  chloral  are 
useful  to  relieve  pain  and  restlessness.  After  four  or  five  days, 
in  all  cases  where  there  is  much  prostration,  strychnia  gr. 
sWjr*  should  be  added  to  the  quinine,  and  tincture  of  digitalis 
HI  x.,  should  be  given  three  or  four  times  a  day  to  stimulate  the 
heart.  Alcoholics  or  carbonate  of  ammonium  are  required 
when  there  is  much  prostration.  The  latter  is  evanescent  in 
its  effects,  but  acts  promptly.  Iodide  of  ammonium,  carbonate 
of  ammonium,  chloride  of  ammonium,  liquor  potassae,  or 
acetate  of  potassium  are  useful  in  the  latter  stages  to  favor 
resolution  and  prevent  caseation.  Late  in  the  disease  counter- 
irritation  is  beneficial.  Cathartics  and  blood-letting  should  not 
be  employed  excepting  in  rare  instances,  in  robust  patients. 


LOBULAR   PNEUMONIA. 

127 

When  patients  are  much  prostrated  and  delirious,  great  care 
should  be  taken  to  prevent  them  from  sitting  up  or  getting  out 
of  bed,  for  this  will  sometimes  cause  immediate  death. 


LOBULAR   PNEUMONIA. 

Synonyms.— Catarrh al  pneumonia;  Broncho-pneumonia;  Dis- 
seminated pneumonia.  Chronic  or  interstitial  or  interlobular 
pneumonia  is  often  included  in  this  term. 

This  is  usually  a  disease  of  childhood  or  of  old  age.  It  is 
preceded  by  bronchitis  affecting  the  smaller  tubes,  and  the 
inflammation  is  confined  to  small  portions  of  the  parenchyma, 
involving  only  a  single  lobule  or  group  of  lobules  which  are 
scattered  through  the  lung.  The  nodules  thus  formed  vary 
from  the  size  of  a  mustard-seed  to  that  of  a  walnut.  They 
are  often  surrounded  by  emphysematous  air-cells.  One  lung 
or  both  lungs  may  be  involved,  and  either  the  upper  or  lower 
lobe  may  be  affected. 

SYMPTOMS. 

The  essential  symptoms  are  rapidity  of  the  pulse  and  of  respi- 
ration ;  with  usually  great  elevation  of  temperature,  a  trouble- 
some cough  and  rapid  emaciation. 

SIGNS. 

The  most  important  signs  are  deficient  respiratory  move 
ments,  slight  and  occasionally  "  patchy  "  dulness,  with  deficient 
vesicular  murmur  an3  on  forced  inspiration,  numerous  poorly 
defined  mucous  clicks.  When  only  a  limited  number  of  lobules 
are  affected,  a  diagnosis  cannot  be  accurately  made ;  but  if 
several  lobules  are  involved,  the  signs  become. quite  distinct. 

INSPECTION. — We  will  usually  observe  imperfect  respiratory 
movements,  with  very  slight  expansion  of  the  ribs,  but  con- 
siderable elevation  of  the  chest-walls,  especially  at  the  upper 
part  during  inspiration ;  and  at  the  same  time  falling-in  of  the 
soft  parts  of  the  chest  and  of  the  lower  ribs,  as  in  pulmonary 
emphysema.  The  respiratory  movements  are  rapid ;  the 
inspiration  is  often  shortened  and  the  expiration  prolonged. 

PALPATION. — When  several  inflamed  nodules  exist,  especially 
if  they  are  located  near  the  surface  of  the  lung,  palpation  will 
discover  exaggerated  vocal  fremitus. 


I2g  PULMONARY   DISEASES. 

PERCUSSION.— Upon  percussion,  dulness  will  be  found  vary- 
ing in  degree  with  the  amount  of  consolidation.  This  is  nearly 
always  limited  to  the  inferior  and  posterior  portions  of  the 
chest,  and  usually  occurs  on  both  sides ;  but  the  disease  may 
be  confined  to  one  lung  or  to  the  upper  lobes  of  the  lungs. 

AUSCULTATION. — More  or  less  broncho-vesicular  or  bron- 
chial respiration  with  exaggerated  vocal  resonance  and  moist 
high-pitched  rales  will  be  found  over  the  lower  part  of  the 
lungs.  At  the  same  time,  over  the  upper  and  anterior  portions 
of  the  chest,  we  ordinarily  find  the  signs  of  pulmonary  emphy- 
sema, viz.,  vesiculo-tympanitic  resonance  with  a  prolonged  and 
low-pitched  expiratory  murmur. 

After  protracted  or  repeated  colds,  the  occurrence  of  a  feeble 
vesicular  murmur,  with  several  illy-defined  mucous  clicks  on 
forced  inspiration,  should  cause  us  to  suspect  lobular  pneu- 
monia. The  mucous  clicks  in  these  cases  are  due  to  retention 
of  the  catarrhal  products  in  the  air-cells. 

High-pitched  bronchial  rales  are  also  significant  of  consoli- 
dation. In  children  the  alveoli  are  often  completely  choked, 
so  that  no  rales  are  produced.  In  adults,  the  inflammatory 
products  are  more  fluid,  and  consequently  rales  are  more 
abundant. 

The  diagnosis  of  this  disease  is  very  difficult,  unless  a  con- 
siderable number  of  lobules  are  affected.  Even  then,  the 
disease  cannot  always  be  detected  by  the  physical  signs  alone, 
but,  as  in  some  cases  in  other  affections  of  the  lungs,  the 
history  and  symptoms  must  be  weighed 'with  the  signs,  before 
a  positive  opinion  can  be  formed.  For  example,  in  a  child 
suffering  from  bronchitis,  if  the  respiration  suddenly  becomes 
accelerated,  the  temperature  elevated,  and  the  cough,  which 
may  previously  have  been  loose  and  easy,  becomes  dry, 
paroxysmal,  hacking,  and  painful,  we  have  good  reason  to  think 
that  the  vesicular  portion  of  the  lung  has  become  involved  in 
the  inflammatory  process.  If  in  addition  to  these  symptoms, 
we  find  the  signs  of  consolidation  which  have  just  been 
enumerated,  the  diagnosis  may  be  considered  certain. 

Lobular  pneumonia  is  often  preceded  and  accompanied  by 
collapse  or  atelectasis,  of  many  of  the  air-vesicles  ;  for  this 
reason  the  signs  of  the  two  diseases  are  usually  considered 
identical.  If  any  considerable  amount  of  tissue  is  involved, 


LOBULAR   PNEUMONIA. 


I29 


and  the  two  conditions  are  not  combined,  a  differential  diag- 
nosis can  be  made  by  attention  to  the  following  symptoms  and 

signs. 

LOBULAR  PNEUMONIA.  PULMONARY  COLLAPSE. 

Symptoms. 

Temperature  suddenly  increased;  cough  The" elevation  of  temperature,  and  the 

becomes  dry  and  paroxysmal.  cough,  which  are  incidental  to  the  associ- 

ated bronchitis,  are  not  materially  affected 
by  collapse  of  the  air-vesicles. 
Inspection, 

Falling-in  of  the  lower  portions  of  the  The  inverted  action  of  the  inferior  ribs 

chest  which  may  have  been  noticed  in         is  increased  in  proportion  to  the  extent  of 


bronchitis  partially  disappears. 


Vocal  fremitus  is  increased. 


atelectasis. 
Palpation. 

The  vocal  fremitus  is  not  likely  to  be 

increased,  but,  on  the  contrary,  it  may  be 

diminished. 
Percussion. 


Uniform  dulness,  or  distinct  patches 
of  dulness,  usually  marked  over  the  lower 
portions  of  the  chest. 


The  dulness  is  not  so  distinct,  and 
there  is  occasionally  vesiculo-tympanitic 
resonance. 

The  dulness  usually  occurs  first  at  the 
border  of  the  left  lung,  where  it  overlaps 
the  heart ;  and  shortly  afterwards  at  the 
base  of  the  lungs.  From  the  latter  position 
it  has  a  tendency  to  spread  upward  in  an 
elongated,  somewhat  pyramidal  form  along 
the  lines  of  the  intervertebral  grooves,  in 
which  position  it  may  reach  as  high  as  the 
apex  of  the  lung. 
Auscultation. 


The  respiratory  sounds  usually  feeble. 
The  rales  of  bronchitis  are  less  likely  to 
be  present  than  in  lobular  pneumonia, 
and  they  are  seldom  heard  over  the  col- 
lapsed lobules.  Sometimes  deep  inspira- 
tions may  bring  out  a  few  crepitant  rales, 
which  are  heard  with  three  or  four  inspi- 
ratory  acts,  and  then  disappear. 


The  respiratory  sounds  are  generally 
harsh  or  broncho-vesicular  in  quality, 
but  they  are  never  wholly  tubular.  The 
mucous  rales  of  bronchitis  are  usually- 
heard  over  the  entire  chest ;  but,  in  many 
instances,  finer  moist  rales  are  obtained, 
limited  to  a  small  space  immediately  over 
the  inflamed  lobules.  When  the  finer 
bronchi  are  dilated,  as  sometimes  hap- 
pens in  this  disease,  the  rales  become 
coarse  and  somewhat  metallic,  if  the  dila- 
tations are  surrounded  by  consolidated 
lung. 

TREATMENT. 

This  disease  is  nearly  always  a  secondary  affection,  due  to 
extension   of    the   inflammatory   process   from   the   bronchial 
9 


PULMONARY  DISEASES. 

J 

mucous  membrane  in  consequence  of  debility.  .Bearing  this 
in  mind  we  will  avoid  all  depressing  remedies  such  as  anti- 
mony,  aconite,  or  veratrum  viride,  and  will  very  early  com- 
mence the  use  of  stimulants. 

Quinine  is  the  best  remedy  to  moderate  the  fever.  Alcoh 
should  be  given  according  to  the  amount  of  depression.  The 
rule  is  to  give  as  much  as  can  be  borne  without  causing  head 
symptoms.  Carbonate  of  ammonium  or  iodide  of  ammonium 
are  very  useful,  not  only  for  the  stimulation  which  they  afford, 
but  also  for  their  beneficial  effects  in  removing  the  products  of 
inflammation. 

Sedative  inhalations  are  useful  early  in  the  attack,  and  at  a 
later  period  stimulant  inhalations  and  counter-irritation  are 
beneficial.  If  the  patient  emaciate,  chloride  of  calcium,  tinc- 
ture of  iron,  and  cod-liver  oil  are  indicated.  A  change  of 
climate  is  advisable  if  recovery  does  not  take  place  within 
eight  or  ten  weeks. 


PECULIAR   FORMS   OF   PNEUMONIA. 

Several  somewhat  peculiar  forms  ot  pneumonia  merit  pass- 
ing consideration,  though  they  cannot  be  considered  as  distinct 
varieties  of  the  disease.  These  are :  interstitial  pneumonia, 
typhoid  pneumonia,  pneumonia  secondary  to  typhoid  fever, 
pneumonia  due  to  cardiac  disease,  and  pneumonia  from  Bright's 
disease. 

The  treatment  of  these  varieties  is  essentially  the  same  as 
that  for  the  diseases  with  which  they  are  associated,  combined, 
as  occasion  may  seem  to  require,  with  the  resolvents  and  expec- 
torants mentioned  in  speaking  of  lobular  pneumonia. 

CHRONIC  OR  INTERSTITIAL  PNEUMONIA 

(sometimes  termed  catarrhal   pneumonia)  will    be    described 
under  the  head  of  fibroid  phthisis. 

TYPHOID  PNEUMONIA. 

Synonyms. — Infective  or  pathogenic  pneumonia. 
This  is  a  somewhat  peculiar  inflammation  of  the  lung  arising 
from  blood-poisoning. 

The  symptoms  are  similar  to  those  of  typhoid  fever  or  septi- 


PULMONARY   CONGESTION.  ,-, 

casmia,  and  are  occasionally  prolonged  for  several  months, 
with  repeated  remissions  and  exacerbations. 

The  only  peculiar  signs  are :  irregular  subcrepitant  rales,  few 
in  number,  heard  sometimes  at  the  base,  and  sometimes  at  the 
apex  of  the  lung.  They  occur  during  both  portions  of  the 
respiratory  act,  and  have  a  peculiar  viscid  quality. 

PNEUMONIA,  SECONDARY  TO  TYPHOID  FEVER, 

usually  commences  during  the  later  stages  of  the  febrile  affec- 
tion.    It  is  indicated  by  increased  rapidity  of  the  pulse,  and 
by  accelerated  respirations  with  signs  of  consolidation. 
Cough  and  sanguinolent  sputa  are  rarely  present. 

PNEUMONIA  ARISING  FROM  DISEASE  OF  THE  HEART, 

especially  when  mitral  lesions  are  marked,  presents  many  feat- 
ures similar  to  those  of  lobular  pneumonia.  The  invasion  is 
usually  slow,  being  seldom  preceded  by  rigors.  There  is  a 
chronic  cough,  with  bronchial  sputa,  which  seldom  becomes 
rusty  or  tenacious.  The  signs  may  appear  in  scattered  patches, 
which  change  their  seat  from  day  to  day,  but  they  are  usually 
found  over  the  lower  lobes  of  both  lungs. 

There  is  some  exaggeration  of  the  vocal  fremitus,  slight  dul- 
ness,  and  blowing  though  not  strictly  bronchial  respiration, 
with  exaggerated  vocal  resonance. 

PNEUMONIA   FROM   BRIGHT'S   DISEASE 

may  not  differ  materially  from  ordinary  acute  pneumonia,  or  it 
may  begin  in  collapse  of  portions  of  the  vesicular  structure, 
and  present  characteristics  similar  to  those  of  lobular  pneu- 
monia. 

PULMONARY   CONGESTION. 

This  consists  of  an  engorgement  of  the  capillaries  within  the 
lungs,  and  affects  both  sides.  It  possesses  no  distinctive  phys- 
ical signs  unless  associated  with  pulmonary  oedema  or  bron- 
chial hemorrhage. 

In  the  congestion  of  the  lung  which  immediately  precedes 
pneumonia,  physical  examination  reveals  very  slight  dulness, 
with  feebleness  of  the  respiratory  murmur  and,  possibly  here 
and  there,  a  crepitant  or  subcrepitant  rale.  This  condition, 


PULMONARY   DISEASES. 

however,  is  not  usually  included  under  the  head  of  pulmonary 
congestion. 

SYMPTOMS  AND  SIGNS. 

In  the  condition  which  is  usually  termed  pulmonary  con- 
gestion, we  can  only  judge  of  the  nature  of  the  case  by  its 
history  and  its  symptoms,  taken  in  connection  with  the  physi- 
cal signs.  For  example,  if  a  patient  is  attacked  with  sudden 
dyspnoea  after  extreme  physical  exertion  or  exposure  to  the 
influence  of  a  rarefied  atmosphere,  as  in  high  altitudes,  pul- 
monary congestion  should  be  suspected ;  and  if  the  dyspnoea 
is  attended  with  a  profuse  watery  and  blood-stained  expecto- 
ration and  the  signs  of  cedema,  we  may  be  positive  of  our 
diagnosis. 

PERCUSSION. — In  such  cases  percussion  reveals  slight  dulness 
over  the  lower  portions  of  the  chest. 

AUSCULTATION  enables  us  to  hear  a  feeble  respiratory  mur- 
mur with  crepitant  rales,  attended  usually  by  an  abundance  of 
large  and  small  mucous  rales  due  to  secretions  in  the  bronchial 
tubes. 

Accentuation  of  the  second  sound  of  the  heart,  at  the  pul- 
monary orifice,  has  been  considered  by  some  authors  to  be 
diagnostic  of  this  affection ;  but  this  sign  cannot  be  relied  on,  as 
it  may  be  only  relative,  due  to  feebleness  of  the  aortic  sound  ; 
and  again  this  accentuation  is  a  common  sign  in  cardiac  disease. 

TREATMENT. 

When  the  congestion  comes  on  suddenly,  full  doses  of 
ergot  should  be  given.  Bleeding  will  be  found  useful  in 
cases  of  extreme  plethora.  Dry  or  wet  cupping  is  sometimes 
beneficial.  A  blister  will  occasionally  prevent  the  superven- 
tion of  inflammation.  If  the  heart  is  weak,  it  should  be  stimu- 
lated, and  if  pulmonary  cedema  co-exist,  a  hydragogue  cathar- 
tic should  be  administered. 


LECTURE   XIII. 
DISEASES   OF   THE  LUNGS— Continued. 

PULMONARY   HEMORRHAGE. 

Hemorrhage  into  the  bronchial  tubes  obstructs  the  entrance 
of  air,  and  causes  more  or  less  quickening  of  the  respiratory 
movements.  It  produces  mucous  rales  similar  to  those  found 
in  bronchitis.  The  diagnosis  must  rest  upon  the  bloody  and 
frothy  character  of  the  expectoration,  and  the  presence  of 
mucous  rales  over  that  portion  of  the  lung  where  the  hemor- 
rhage has  taken  place. 

TREATMENT. 

The  patient  should  be  kept  perfectly  quiet  until  all  bleeding 
ceases. 

The  most  efficient  remedies  for  checking  the  hemorrhage  are 
full  doses  of  ergot,  gallic  acid,  or  acetate  of  lead  and  opium. 

The  hemorrhage  may  often  be  checked  by  the  inhalation  of 
a  spray  from  a  weak  solution  of  liquor  ferri  subsulphatis — 1*1  x., 
aqua  ad  §  i. 

PULMONARY   APOPLEXY. 

Pulmonary  apoplexy,  or  hemorrhagic  infarctus,  is  a  rare 
affection,  consisting  of  extravasations  of  blood  into  the  lung 
tissue.  It  usually  occurs  in  the  lower  lobes. 

SYMPTOMS. 

This  accident  is  usually,  though  not  invariably,  attended  with 
dyspnoea  and  haemoptysis. 

SIGNS. 

The  principal  signs  are :  more  or  less  dulness,  feeble  or  bron- 
chial respiration,  and  mucous  rales. 

PERCUSSION. — When  the  coagula  are  few  in  number,  and 
small  or  deep-seated,  percussion  yields  no  signs ;  but  if  they  are 
numerous,  or  lie  superficially,  dulness  will  be  more  or  less 
marked. 


PULMONARY   DISEASES. 
J34 

AUSCULTATION.— Upon  auscultation,  mucous,  subcrepitant, 
and  possibly  well-marked  crepitant  rales  'will  be  detected  in 
and  about  the  extravasations,  until  coagulation  of  blood  has 
taken  place.  Afterwards,  the  respiration  will  be  feeble  or  sup- 
pressed over  the  extravasations;  or  bronchial  breathing  and 
exaggerated  vocal  resonance  may  be  obtained,  if  a  large  clot 
lies  in  apposition  with  a  patent  bronchial  tube. 

DIAGNOSIS. 

The  diagnosis  of  this  affection  must  be  based  upon  the  his- 
torv  and  the  character  of  the  sputa,  taken  in  connection  with 
the  signs  found  upon  percussion  and  auscultation.  This  condi- 
tion is  not  likely  to  be  mistaken  for  any  other  disease  except 
pneumonia,  from  which  it  can  easily  be  distinguished  by  the 
history  and  by  the  expectoration. 

TREATMENT. 

The  treatment  should  be  mainly  directed  to  the  cause  of  the 
hemorrhage.  Removal  of  the  blood-clot  is  probably  hastened 
by  the  administration  of  iodide  of  potassium,  or  liquor  potassae 
or  other  alkalies.  Counter-irritation  is  useful  in  some  cases  a 
few  days  after  the  accident.  Quiet  must  be  maintained  for 
two  or  three  weeks  to  prevent  a  recurrence  of  the  attack.  If 
pneumonia  or  pleurisy  supervene,  they  should  be  treated  essen- 
tially the  same  as  when  they  occur  alone. 

PULMONARY   THROMBOSIS   AND    EMBOLISM. 

The  first  of  these  conditions  consists  of  plugging  of  the 
blood-vessels,  by  a  coagulum,  resulting  from  some  neighboring 
irritation.  The  second  consists  of  plugging  of  the  blood-vessels, 
usually  by  fragments,  of  a  coagulum,  or  of  vegetations  on  the 
surface  of  the  mitral  or  aortic  valves.  In  the  former  case,  the 
pulmonary  artery,  or  some  of  its  branches  is  likely  to  be 
occluded  by  a  clot  carried  from  the  veins  in  the  lower  part  of 
abdomen,  or  of  the  inferior  extremities  ;  in  the  latter  case,  some 
of  the  bronchial  arteries  are  obstructed  by  fragments  washed 
from  the  vegetations  on  the  mitral  or  aortic  valves. 

SYMPTOMS   AND   SIGNS. 

The  principal  symptoms  are  sudden,  severe,  and  sometimes 
paroxysmal  dyspnoea,  turbulent  action  of  the  heart,  and  pulsa- 
tion of  the  jugular  veins,  from  yielding  of  the  tricuspid  valve. 


PULMONARY   COLLAPSE.  j_- 

Exaggerated  resonance  is  sometimes  detected,  owing  to  cut- 
ting off  of  the  blood  supply  to  some  of  the  pulmonary  lobules, 
and  consequent  distention  of  the  air-cells.  In  the  same  locality, 
the  respiratory  murmur  will  be  feeble  or  suppressed. 

DIAGNOSIS. 

Neither  the  symptoms  nor  the  signs  of  these  conditions  are 
sufficiently  well  understood  to  enable  us  to  make  a  positive 
diagnosis  in  every  instance.  Most  reliance  must  be  placed  on 
the  symptoms. 

TREATMENT. 

The  treatment  must  be  expectant. 

PULMONARY  COLLAPSE. 

Synonyms, — Apneumatosis  and  Atelectasis.  The  latter  term, 
though  referring  to  the  same  anatomical  condition,  is  more 
properly  applied  to  air-cells  which  remain  in  the  foetal  condition 
after  birth,  never  becoming  distended  with  air. 

Formerly  this  affection  was  described  by  different  authors  as 
lobular  pneumonia,  carnification  of  the  lung,  catarrhal  pneu- 
monia, and  so  on.  Lobular  (catarrhal)  pneumonia  I  have  already 
spoken  of.  The  term  carnification  should  be  restricted  to  the 
hardened  condition  in  which  the  lung  is  found  after  having 
been  subjected  to  compression  by  pleuritic  effusions. 

Pulmonary  collapse  or  apneumatosis  is  a  condition  of  the 
lungs  in  which  portions  of  the  air-cells,  which  have  formerly 
been  inflated,  have  collapsed,  and  returned  to  a  quasi-foetal 
state.  As  a  result  of  this  change,  adjacent  air-cells  become 
more  or  less  emphysematous.  The  affection  is  most  frequent  in 
early  childhood.  It  is  always  preceded  by  inflammation  of  the 
bronchial  mucous  membrane,  the  secretions  from  which  col- 
lect in  some  of  the  smaller  bronchial  tubes,  where,  acting  as  a 
ball  valve,  they  obstruct  the  entrance  of  air  during  inspiration, 
but  permit  its  escape  in  expiration.  Ultimately  the  air-cells  to 
which  the  obstructed  bronchus  is  distributed,  become  in  this 
manner  completely  emptied  of  air  and  collapsed.  This  may 
affect  only  a  few  lobules ;  or  a  great  number  of  lobules  may  be 
implicated,  and  sometimes  an  entire  lobe  is  involved.  Usually 
all  the  lobes  of  both  lungs  are  more  or  less  affected. 

Certain  portions  of  the  lung  are  affected  most  frequently. 


6  PULMONARY  DISEASES. 

These  are:  first  the  lower  margins  of  the  lower  lobes  of  both 
lungs;  then,  the  tongue-like  prolongation  of  the  upper  left 
lobe,  and  the  middle  lobe  of  the  right  lung ;  next  in  order  come 
the  posterior  surfaces  near  the  spinal  column,  of  the  lower  and 
upper  lobes  of  both  lungs. 

SYMPTOMS. 

The  essential  symptoms  are:  great  prostration,  pallor,  or 
duskiness  of  the  skin,  which  hangs  in  loose  folds  on  the  ema- 
ciated limbs ;  rapid  feeble  pulse  and  coldness  of  the  extremities  ; 
a  feeble  insufficient  cough  ;  great  dyspnoea,  without  the  lividity 
which  usually  attends  this  symptom,  and  rapid  respiration,  ris- 
ing, in  young  children,  from  sixty  to  eighty  per  minute,  with 
an  altered  rhythm  in  the  respiratory  acts.  In  this  alteration  of 
rhythm  the  pause  follows  inspiration,  and  precedes  expiration, 
instead  of  occurring  between  expiration  and  inspiration,  as  in 

health. 

SIGNS. 

The  essential  signs  are :  retraction  of  the  intercostal  spaces 
and  lower  ribs  during  inspiration,  dulness  over  the  collapsed 
lung  when  the  apneumatosis  is  considerable,  and  feeble  or 
absent  vesicular  murmur,  usually  with  harsh  or  bronchial  respi- 
r^tion  over  the  affected  parts. 

INSPECTION. — By  inspection  we  notice  the  rapidity  of  the 
respiration  and  its  changed  rhythm — the  interval  occurring- 
between  inspiration  and  expiration,  instead  of  between  expira- 
tion and  inspiration — and  retraction  of  the  intercostal  spaces 
and  lower  ribs  during  inspiration.  This  latter  is  a  very  important 
sign,  but  it  must  not  be  forgotten  that  it  occurs  in  other  diseases. 

PERCUSSION. — In  children  the  signs  of  percussion  are  not  so 
reliable  as  in  adults,  but  when  the  disease  is  well  marked,  more 
or  less  dulness  will  be  found  over  the  affected  portions,  usually 
first  at  the  base  of  the  lungs,  then  at  their  anterior  borders,  and 
finally  along  the  spinal  column.  If  a  whole  lobe  is  involved, 
dulness  like  that  of  pneumonia  will  be  present.  Not  infre- 
quently the  collapsed  cells  are  so  scattered  through  the  lungs, 
and  the  adjacent  cells  are  so  distended,  that  the  affection  may 
be  quite  extensive  without  giving  any  signs  on  percussion. 

AUSCULTATION. — The  vesicular  murmur  is  absent  over  the 
collapsed  cells,  and  in  its  stead  we  hear  harsh  or  bronchial  res- 
piration. 


PULMONARY   COLLAPSE.  j.- 

Usually  portions  of  the  lung  immediately  surrounding  the 
affected  lobules  remain  pervious  to  air,  so  that  the  vesicular 
murmur  is  not  entirely  lost.  As  a  result  the  sounds  from  the 
air-vesicles  are  mingled  with  those  from  the  bronchi,  causing 
broncho-vesicular  respiration.  Ordinarily  numerous  bronchial 
rales  are  present,  which  may  completely  mask  the  vesicular 
murmur. 

DIFFERENTIAL   DIAGNOSIS. 

The  diagnosis  in  many  cases  must  depend  mainly  on  the 
symptoms,  as  the  signs  are  by  no  means  distinctive.  When- 
ever dulness  occurs,  its  rapid  appearance,  within  twenty-four 
or  thirty-six  hours  succeeding  the  signs  of  bronchitis,  is  an  ele- 
ment of  great  value  in  diagnosis. 

Pulmonary  collapse  is  most  likely  to  be  mistaken  for  pneu- 
monia or  pleuritic  effusions. 

Pneumonia. — In  pulmonary  collapse  we  find  few  if  any  crepi- 
tant  rales  which  are  considered  pathognomonic  of  pneumonia. 
In  the  latter  disease  there  is  not  the  retraction  of  the  chest  noticed 
in  collapse,  and  dulness  is  usually  greater  and  the  bronchial 
breathing  more  marked  than  in  the  disease  under  consideration 
(see  page  125). 

Pleurisy. — The  distinctive  features  that  characterize  pleurisy 
and  pulmonary  collapse  were  considered  in  speaking  of  the 
former  (see  page  92). 

TREATMENT. 

In  the  treatment  of  this  condition  it  must  not  be  forgotten 
that  debility  is  the  chief  factor  in  its  production.  Our  treat- 
ment must  therefore  be  supporting  from  the  first.  We  must 
also  attempt  to  remove  the  secretions  from  the  bronchi,  so  as  to 
prevent  implication  of  other  air-cells.  With  this  in  view  a  non- 
depressing  emetic  may  be  given  when  the  debility  is  not  very 
great,  but  it  is  generally  unsafe  to  repeat  it.  In  mfld  cases 
expectorant  doses  of  ipecac  are  useful.  In  severe  cases  carbo- 
nate of  ammonium  or  iodide  of  ammonium  with  alcoholic 
stimulants  are  indicated.  Counter-irritation  of  the  surface  by 
means  of  vigorous  friction  or  sinapisms  is  useful  in  most  cases. 
The  diet  should  be  nourishing,  but  not  too  concentrated.  Con- 
centrated nourishment  often  deranges  the  digestive  organs, 
and  thus  does  more  harm  than  good. 


g  PULMONARY   DISEASES. 

PULMONARY   OEDEMA. 

This  consists  of  an  effusion  of  serum  into  the  vesicular  por- 
tion of  the  lungs,  which  renders  the  cells  impervious  to  air. 
It  is  frequently  associated  with  general  dropsy.  It  may  result 
from  the  adynamic  condition  following  protracted  fever,  or  it 
may  be  caused  by  renal  or  by  cardiac  disease,  and  it  occasion- 
ally follows  bronchitis  or  pneumonia. 

SYMPTOMS. 

The  symptoms  are  not  distinctive. 

SIGNS. 

The  principal  signs  are  very  moist  subcrepitant  rales,  with 
more  or  less  dulness  over  the  base  of  the  lungs. 

INSPECTION,  PALPATION,  AND  MENSURATION  yield  no  charac- 
teristic signs.  The  respirations  are  increased  in  frequency. 

PERCUSSION. — Dulness  is  obtained  on  both  sides  over  the 
most  dependent  portions  of  the  lungs. 

AUSCULTATION. — There  is  a  feeble  respiratory  murmur  which 
may  be  slightly  broncho-vesicular,  with  abundant  moist  and 
crackling  subcrepitant  rales.  These  sometimes  resemble  the 
crepitant  Vales  of  pneumonia,  but  they  are  more  moist,  not  so 
numerous,  and  usually  they  are  heard  in  expiration  as  well  as 
in  inspiration.  The  vocal  resonance  may  be  increased. 

DIFFERENTIAL   DIAGNOSIS. 

Pulmonary  oedema  is  liable  to  be  mistaken  for  the  first  and 
the  third  stages  of  pneumonia,  for  hydrothorax,  and  for  capil- 
lary bronchitis.  The  distinctive  signs  between  these  diseases 
are  as  follows.* 

PULMONARY  OADEMA.  PNEUMONIA,  FIRST  AND  THIRD  STAGES. 

Percussion. 
Slight  dukiess  upon  both  sides.  Dulness  more  or  less  marked,  usually 

confined  to  one  side. 
Auscultation. 

Mucous  and  subcrepitant  rales  on  both  Crepitant  and  subcrepitant  rales  on  one 

sides.  side. 

PULMONARY  OZDEMA.  HYDROTHORAX. 

Palpation. 

Vocal  fremitus  may  or  may  not  be  in-  Vocal  fremitus  absent. 

creased. 

*  Signs  common  to  both  are  omitted. 


PULMONARY   (EDEMA.  n 

^ -^ 

Percussion. 

Moderate  dulness,  the  upper  level  of  Flatness,  the  upper  line  of  which  varies 

which  does  not  vary  with  changes  in  the        with  the  changes  in  the  patient's  position, 
patient's  position. 

Auscultation. 

Subcrepitant  rales.  Absence  of  the  respiratory  murmur  and 

rales. 

Pulmonary  oedema  is  distinguished  from  capillary  bronchitis 
by  the  history,  by  the  presence  of  considerable  dulness  on  per- 
cussion, and  by  absence  of  the  signs  of  general  bronchitis  (see 
page  103). 

TREATMENT. 

The  treatment  of  this  condition  will  depend  upon  the  disease 
with  which  it  is  associated.  If  it.  results  from  Bright's  disease, 
sudorifics  and  cathartics  will  be  necessary  to  stimulate  the 
other  emunctories.  Diuretics  will  also  be  useful  in  some  cases ; 
but  we  must  not  forget  that  the  kidneys  are  crippled  and  will 
not  respond  readily  to  our  efforts  to  increase  their  functional 
activity. 

If  the  condition  is  dependent  upon  disease  of  the  heart, 
digitalis  will  be  specially  useful.  If  it  results  from  debility, 
induced  by  low  forms  of  disease,  general  stimulation  is  very 
essential,  and  diuretics  and  sudorifics  are  indicated. 

If  it  results  from  pulmonary  congestion,  active  counter- 
irritation  by  sinapisms  or  dry  cups  should  be  made,  and  diuret- 
ics, sudorifics,  and  cathartics  should  be  simultaneously  em- 
ployed, care  being  taken  not  to  exhaust  the  patient. 

Digitalis,  scoparius,  acetate  of  potassium,  and  acetate  of 
ammonium  are  the  best  diuretics.  Jaborandi  and  the  hot-air 
or  vapor  bath  are  the  most  suitable  means  to  cause  sweating. 

The  saline  cathartics,  elaterium  or  euonymus,  may  be  em- 
ployed when  it  is  desired  to  act-on  the  bowels. 

When  patients  are  greatly  depressed  from  protracted  disease, 
care  should  be  taken  to  prevent  pulmonary  oedema  by  frequently 
changing  their  position  from  the  back  to  the  sides,  and  vice 
versa. 


PULMONARY  DISEASES. 


PULMONARY   GANGRENE. 

Pulmonary  gangrene  is  a  putrefactive  necrosis  of  lung  tissue, 
resulting  from  pneumonia,  septicaemia,  or  local  injuries.  It 
usually  occurs  at  the  lower  part  of  the  lung,  and  according 
to  Prof.  Flint,  on  the  posterior  aspect  of  the  upper  portion  of 
the  lower  lobe.  The  affection  is  usually  confined  to  a  few 
lobules,  but  sometimes  it  is  diffused  throughout  a  large  portion, 
or  even  throughout  the  whole  of  a  lobe. 

SYMPTOMS. 

The  principal  symptoms  are  great  prostration,  pallor,  emaci- 
ation, rapid  pulse,  rapid  and  oppressed  respiration,  haemoptysis, 
and  cough  with  abundant  greenish  or  brownish  purulent 
sputa  of  a  sickening  gangrenous  odor,  and  containing  frag- 
ments of  the  decomposing  lung.  The  odor  is  not  perceived  in 
the  breath  constantly,  but  mainly  after  coughing. 

SIGNS. 

The  most  prominent  signs  are :  dulness  on  percussion,  with 
large  and  small  mucous  rales :  bronchial  breathing  or  absence 
of  the  respiratory  murmur,  and,  when  the  slough  has  been 
thrown  off,  gurgles  and  respiratory  sounds  indicative  of  a 
cavity.  The  disease  at  first  presents  the  signs  of  consolidation, 
which  are  soon  followed  by  breaking-down  of  the  lung  tissue, 
and  the  production  of  vomicae. 

DIFFERENTIAL  DIAGNOSIS. 

Most  of  the  symptoms  and  physical  signs  are  not  distinctive, 
as  the  same  may  be  found  in  phthisis,  bronchitis,  or  dilatation 
of  the  bronchial  tubes.  Th£  diagnosis  must  therefore  rest 
upon  the  character  and  the  odor  of  the  expectoration,  which 
may  be  considered  pathognomonic. 

Bronchitis. — Small  circumscribed  patches  of  gangrene,  which 
occasionally  occur  in  bronchitis,  or  around  tubercular  deposits, 
cause  fetid  breath  and  fetid  expectoration.  The  odor  in  these 
cases  is  only  temporary,  whereas,  in  diffuse  gangrene,  the  fetor 
is  persistent,  though  most  marked  after  each  act  of  cough 
and  expectoration. 

Bronchiectasis. — In  bronchial  dilatation  the  sputum  is  abundant 


PULMONARY   CANCER.  j 

and  fetid,  but  not  brownish  in  color,  and  the  breath  has  not 
that  peculiar,  sickening  odor  of  gangrene,  which,  once  im- 
pressed on  the  olfactory  sense,  can  never  be  forgotten. 

TREATMENT. 

Quinine,  tincture  of  iron,  alcoholics,  and  nourishing  diet 
are  the  chief  remedies  in  this  affection.  Inhalations  of  car- 
bolic acid  or  turpentine  may  be  useful  in  modifying  the  offen- 
sive odor  and  in  limiting  the  amount  of  discharge.  Anodynes 
should  be  used  to  soothe  pain. 

TUMORS   OF   THE   LUNGS. 

Morbid  growths  in  the  lungs  result  from  enlargement  of 
glands,  syphilis,  hydatids,  abscesses,  and  malignant  disease. 
These  will  be  considered  under  their  respective  headings. 

PULMONARY  CANCER. 

Pulmonary  cancer  is  fortunately  a  rare  disease ;  the  medullary 
variety  is  the  one  most  frequently  found  in  the  lungs.  Indeed, 
by  Boyle  and  Laennec,  it  was  thought  to  be  the  only  variety 
ever  found  in  these  organs. 

Cancer  may  occur,  in  miliary  bodies  scattered  throughout  the 
entire  lung,  or  in  nodules  ranging  from  two  to  ten  or  twelve 
pounds  in  weight ;  or  the  lung  tissue  may  be  entirely  supplanted 
by  the  malignant  deposit.  When  the  disease  is  primary,  it  is 
very  difficult  to  detect  it.  When  secondary  to  cancer  in  other 
portions  of  the  body,  the  occurrence  and  persistence  of  bron- 
chial or  other  pulmonary  signs  should  lead  us  to  suspect  its 

true  nature. 

SYMPTOMS. 

The  most  marked  symptoms  are  pain  and  emaciation,  with 
some  dyspnoea  and  cough,  and  often  bloody  expectoration. 

SIGNS. 

If  only  the  bronchial  mucous  membrane  is  affected  by  the 
cancerous  deposit,  we  obtain  simply  the  signs  of  bronchitis. 
If  the  air-vesicles  are  filled,  we  obtain  the  signs  of  pulmonary 
consolidation,  as  in  pneumonia.  When  softening  and  ulceration 
have  occurred,  cavernous  signs  are  sometimes  obtained.  If 


PULMONARY  DISEASES. 
142 

part  of  the  air-vesicles  are  filled,  and  others  remain  open,  we 
will  obtain  broncho-vesicular  respiration  and  other  signs  similar 

to  those  of  phthisis. 

The  occurrence  of  the  nodular  variety  of  cancer  in  the  lung 
gives  rise  to  signs  which  are  often  distinctive,  viz.,  dulness  or 
flatness  on  percussion  over  the  upper  or  middle  portions  of  the 
lung,  usually  with  feeble  or  suppressed  respiration,  though 
sometimes  with  harsh,  respiratory  sounds.  If  the  pleura  is 
involved  by  the  cancerous  deposit,  there  will  be  an  exudation 
of  serum  into  its  cavity,  which  will  yield  the  signs  of  chronic 
or  of  subacute  pleurisy.  In  the  nodular  variety  of  pulmonary 
cancer,  we  generally  notice  the  following  signs : 

lNSPECTiON.--Upon  inspection,  we  observe  more  or  less  loss 
of  motion,  and  retraction  of  the  thoracic  walls  on  the  affected 

side. 

PALPATION. — The  vocal  fremitus  will  be  feeble  or  suppressed, 
according  to  the  proximity  of  the  tumor  to  the  chest-walls. 

PERCUSSION. — There  will  be  dulness  or  flatness  over  the 
tumor,  according  to  its  nearness  to  the  chest-walls.  In  many 
instances,  one  or  more  places  may  be  found  where  the  reso- 
nance remains  normal,  surrounded  by  areas  of  flatness.  This  is 
due  to  the  presence  of  a  small  portion  of  healthy  lung  sur- 
rounded by  a  cancerous  mass.  It  is  most  frequently  found 
near  the  middle  or  the  upper  part  of  the  chest. 

AUSCULTATION. — The  respiratory  sounds  will  be  feeble  or 
entirely  suppressed  over  the  tumor.  Occasionally,  the  cancer 
rests  upon  a  large  bronchial  tube,  in  such  a  position  that  the 
sounds  from  the  latter  are  transmitted  to  the  surface,  giving 
rise  to  bronchial  breathing  and  bronchophony. 

DIFFERENTIAL  DIAGNOSIS. 

Pulmonary  cancer  is  most  likely  to  be  mistaken  for  chronic 
or  subacute  pleurisy  with  effusion.  It  bears  some  resemblance 
to  phthisis,  and  some  resemblance  to  aortic  aneurisms. 

Pleurisy.— \i  the  cancer  is  attended  with  effusions  into  the 
pleural  sac,  an  accurate  diagnosis  cannot  be  made  by  the 
ordinary  methods,  but  the  character  of  the  fluid  obtained  by 
aspiration  will  usually  enable  us  to  make  a  correct  diagnosis. 

The  differential  diagnosis  between  the  nodular  variety  of 
cancer  in  the  lungs  and  chronic  pleurisy  will  be  seen  in  the  fol- 
lowing table : 


PULMONARY   CANCER. 

'43 

PULMONARY  CANCER.  CHRONIC  PLEURISY. 

Symptoms. 

Nearly  constant  pain,  and  often  currant-  Little,  if  any,  pain  ;  the  expectoration, 

jelly  expectoration.  if  any,  is  only  purulent. 

Percussion. 

Dulness  does  not  begin  at  the  base  of  Flatness  begins  at  the  base  of  the  lung, 

the  lung,  and  there  are  usually  one  or         and   is   uniform   until  its  upper  limit  is 
more  isolated  spots  of  resonance  within         reached, 
the  area  of  dulness  or  flatness. 

A  uscultation. 

Usually  some  respiratory  signs,  due  to  Absence  of  the  respiratory  murmur,  and 

isolated   portions   of   normal  lung,  or  to         usually  of  the  bronchial  sounds;  the  latter 
only  partial  consolidation  of  the  pulmon-         when  heard  are  diffused  and  distant, 
ary  parenchyma. 

Aspiration. 

Sometimes  a  sanguinolent  fluid.     The  Serous  or  purulent  fluid  is  obtained, 

fluid,  when  serous,  coagulates  much  more 
slowly  than  in  pleurisy. 

Phthisis. — Cancer  of  the  lung  is  not  likely  to  be  mistaken  for 
phthisis,  though  such  an  error  might  be  made.  The  cancerous 
growth  does  not  often  begin  in  the  apex  of  the  lung,  and  it 
may  become  very  extensive  without  causing  bronchial  rales. 
The  reverse  is  true  in  phthisis. 

Aortic  Aneurism. — The  history  of  this  affection  is  different,  as 
intrathoracic  cancer  is  nearly  always  secondary  to  external 
manifestations.  The  symptoms  due  to  pressure,  viz.,  pain, 
dyspnoea,  dysphagia,  and  venous  congestion  and  pulsation,  are 
less  persistent  in  aneurisms  than  in  cancer. 

Aneurisms  usually  have  a  distinct  expansile  pulsation,  and 
when  they  cause  a  murmur,  it  is  likely  to  be  double,  that  is, 
systolic  and  diastolic.  Cancers  have  no  pulsation  excepting 
that  communicated  from  the  aorta,  and  this  is  feeble  and  simply 
lifting.  If  a  cancerous  growth,  by  pressure  on  the  artery,  causes 
a  murmur,  it  is  always  systolic,  no  second  sound  being  pro- 
duced. 

TREATMENT. 

Anodynes  to  relieve  pain  are  the  only  remedies  that  can  be 
recommended.  None  of  the  remedies  which  have  from  time 
to  time  been  recbmmended  for  the  cure  of  cancer  have  borne 
the  test  of  experience. 


PULMONARY   DISEASES. 
'44 


ENLARGED  BRONCHIAL  GLANDS. 

As  an  independent  affection,  this  is  of  rare  occurrence,  but 
more  or  less  enlargement  of  these  glands  is  often  found  in 
phthisis,  with  which  this  condition  has  many  symptoms  and 
signs  in  common.  This  is  generally  a  disease  of  childhood. 

SYMPTOMS. 

The  prominent  symptoms  are:  a  dry,  ringing  and  paroxysmal 
cough  like  that  of  pertussis,  but  without  the  whoop,  with  dysp- 
noea, and  more  or  less  pain  and  tenderness  on  pressure  near 
the  fourth  or  the  fifth  vertebra  ;  associated  with  emaciation, 
hectic  and  night-sweats. 

SIGNS. 

The  essential  signs  are  :  some  tenderness  on  pressure  in  the 
region  of  the  main  bronchi,  with  dulness  in  the  upper  sternal 
region,  and  in  the  interscapular  region  in  advanced  cases.  In 
some  cases  pressure  of  the  enlarged  glands  upon  the  blood-ves- 
sels, causes  distention  of  the  cervical  veins,  and  murmurs  in  the 
arteries.  Pressure  upon  the  bronchial  tubes  is  indicated  by 
permanent  large  bronchial  rales ;  by  harsh  or  deficient  respira- 
tory murmur ;  or  by  absence  of  the  vesicular  sound. 

INSPECTION. — Frequently  we  find  distention  of  the  cervical 
veins  and  sometimes,  though  rarely,  deficiency  or  absence  of 
respiratory  movements  of  one  side,  if  the  main  bronchus  is  oc- 
cluded. 

PALPATION  AND  PERCUSSION. — Tenderness  may  usually  be 
detected  over  the  bronchial  glands  in  the  interscapular  region 
near  the  fourth  and  fifth  dorsal  vertebrae.  Circumscribed  dul- 
ness over  the  enlarged  glands  is  sometimes  found.  Compression 
of  a  bronchus  may  cause  collapse  of  the  lung  with  consequent 
uniform  dulness. 

AUSCULTATION. — We  usually  observe  numerous  rales  and 
feeble  or  harsh  respiration,  or  in  other  words  the  signs  of  con- 
sumption. Sometimes  arterial  murmurs  may  be  detected. 
Again  pressure  on  a  bronchus  may  cause  localized  rales  and 
feeble  respiration ;  or  it  may  prevent  respiratory  sounds  in  the 
portion  of  lung  supplied  by  that  bronchus.  In  these  cases  a 


PERTUSSIS   OR   WHOOPING-COUGH.  T.e 

M5 

deep  breath  will  frequently  bring  out  the  respiratory  sound, 
where  it  could  not  be  heard  in  ordinary  respiration. 

DIFFERENTIAL  DIAGNOSIS. 

This  affection  cannot  usually  be  distinguished  from  phthisis, 
but  in  some  instances,  a  reasonably  certain  differentiation  can 
be  made  by  remembering  that  the  disease  under  consideration 
occurs  at  an  earlier  age  than  phthisis,  and  that  the  pain,  ten- 
derness and  dulness  which  it  induces  are  first  found  in  the 
region  of  the  bronchial  glands,  instead  of  over  the  apex  of  one 
lung. 

TREATMENT. 

Treatment  is  usually  of  little  avail  in  this  disease,  but  the 
remedies  which  are  most  beneficial  in  scrofulous  enlargement 
of  the  superficial  glands  should  be  tried.  Iodine,  iodide  of 
potassium,  chloride  of  calcium,  and  cod-liver  oil  may  be 
used ;  with  quinine  to  relieve  fever,  or  iron  when  fever  is  not 
present. 

The  diet  should  be  plain  but  nutritious,  and  all  the  patient's 
surroundings  should  be  made  as  healthful  as  possible. 

PERTUSSIS   OR  WHOOPING  COUGH. 

This  is  a  spasmodic  affection,  the  result  of  contagion  or  of 
epidemic  influence,  and  mostly  confined  to  children.  The  affec- 
tion is  characterized  by  frequent  paroxysms  of  convulsive 
cough  which  is  followed  by  a  peculiar  stridulous  inspiration  or 
whoop.  The  paroxysms  recur  with  varying  frequency — during 
the  height  of  the  attack  from  fifteen  minutes  to  two  hours  apart. 
The  cough  is  attended  with  vomiting  in  most  cases.  The  matter 
expectorated  consists  of  clear  tenacious  mucus.  Similar  mat- 
ter is  usually  expelled  by  the  acts  of  vomiting.  Blood  is  some- 
times expectorated  or  vomited. 

This  peculiar  cough  is  usually  preceded  by  a  nasal  or  a 
bronchial  catarrh  of  eight  or  ten  days'  duration.  Ordinarily  a 
mild  form  of  bronchitis  attends  the  affection  throughout  its 
entire  course,  and  it  is  likely  to  outlast  the  paroxysmal  attacks. 

Not  infrequently,  acute  bronchitis  or  broncho-pneumonia  is 
developed  in  the  course  of  the  disease. 

The  peculiar  cough  usually  continues  for  several  weeks, 
when  the  whoop  ceases.  In  rare  cases,  it  may  continue  much 


6  PULMONARY   DISEASES. 

longer.     In  exceptional  instances,  the  attack  is  followed  by 
the  development  of  tubercles  in  the  lungs. 

DIAGNOSIS. 

The  diagnosis  rests  upon  the  peculiar  character  of  the  cough. 
Affections  of  the  bronchial  mucous  membrane,  or  of  the  pul- 
monary parenchyma,  which  are  frequently  developed  during 
the  course  of  pertussis,  yield  the  same  signs  as  when  they  oc- 
cur independently. 

TREATMENT. 

Many  "  specifics  "  have  been  Recommended  for  this  disease, 
but  they  have  generally  been  found  of  very  little  service. 

Morphia  and  chloral  given  in  doses  suited  to  the  age  of  the 
patient  seem  to  me  the  most  potent  remedies  in  alleviating  the 
suffering  and  moderating  the  severity  of  the  paroxysms. 

In  many  cases  a  few  doses  of  these  will  prevent  further 
recurrence  of  the  paroxysms.  The  prescription  recommended 
for  asthma  represents  the  proper  dose  for  an  adult  (Form.  3). 

Sulphate  of  quinia  in  large  doses,  given  in  solution  so  as  to 
make  the  strongest  possible  impression  on  the  sense  of  taste, 
has  been  highly  recommended,  and,  according  to  reports  in 
the  current  medical  literature,  will  cure  the  majority  of  cases 
in  a  few  days ;  but  my  own  experience  with  it  has  been  unsat- 
isfactory. 

My  experience  with  the  preparations  of  Anemone  Pratensis 
and  CEnothera  Biennis  has  been  very  limited  but  never  satis- 
factory. 


LECTURE  XIV. 
DISEASES  OF  THE  LUNGS— Continued. 

PULMONARY  PHTHISIS. 

Under  this  head  may  be  gr&uped  several  affections,  differing 
somewhat  in  their  anatomical  characteristics,  but  closely 
resembling  each  other  in  their  physical  signs.  From  this  latter 
fact,  these  affections  are  often  treated  of  as  one  and  the  same 
disease.  This  renders  it  especially  appropriate  for  us,  in  the 
matter  of  diagnosis,  to  consider  them  together.  Therefore, 
when  I  speak  of  phthisis,  I  include  within  the  scope  of  that 
term,  all  those  chronic,  wasting  affections  which  are  attended 
with  exudation  or  infiltration  into  the  pulmonary  parenchyma, 
causing  consolidation,  and  attended  or  followed  by  more  or 
less  induration  and  contraction  ;  and  subsequently  by  breaking 
down  of  lung-tissue.  This  I  do  whether  these  diseases  be  the 
result  of  a  simple  inflammatory  affection,  or  be  the  cause  or 
the  result  of  tubercular  infiltration.  The  term  pulmonary 
phthisis  will  therefore  include  fibroid  phthisis  and  the  ordinary 
acute  and  chronic  forms  of  phthisis,  or  of  pulmonary  consump- 
tion. Any  special  symptoms  or  signs  which  are  of  value  in 
differentiating  between  these  various  conditions  will  be  sepa- 
rately considered. 

Fibroid  phthisis  is  also  known  as  cirrhosis,  induration,  or 
fibroid  degeneration  of  the  lung;  sometimes  as  chronic  catar- 
rhal  pneumonia,  and  occasionally  as  bronchiectasis.  This 
latter  term  relates  to  dilatation  of  the  bronchial  tubes,  the  signs 
of  which  we  have  already  considered. 

The  ordinary  forms  of  phthisis  have  also  been  variously 
named,  as  chronic  croupous  pneumonia;  chronic  catarrhal 
pneumonia ;  cheesy  or  tuberculous  infiltration  of  the  lung ; 
chronic  tuberculosis  ;  and  pneumonic  phthisis. 

Clinically,  these  disease  cannot  usually  be  differentiated, 
and  their  pathology  does  not  properly  fall  within  our  consider- 


g  PULMONARY   DISEASES. 

ation.  The  views  entertained  on  the  pathology  of  the  various 
forms  of  phthisis,  to-day,  by  a  portion  of  the  profession  are 
not  those  which  were  generally  accepted  a  few  years  since, 
and  they  are  themselves  likely  to  be  supplanted  by  others 
within  the  next  decade  ;  therefore,  we  may  well  avoid  this  diffi- 
'cult  subject  until  pathologists  can  more  nearly  agree.  As  has 
been  aptly  said,  "  This  disease  must  not  be  looked  upon  as  a 
single  disease,  beginning  invariably  in  the  same  way,  and 
continuing  in  one  uniform  course,  but  must  rather  be  looked 
upon  as  the  terminus  to  which  any  pulmonary  disease  may 
converge,  and  the  vortex  in  which  all  may  end."* 

SYMPTOMS. 

The  ordinary  symptoms  of  this  disease  are  only  too  well 
known,  even  by  the  laity.  Few  there  are  who  have  not  noticed 
among  their  immediate  friends,  the  bright  and  suffused  eye, 
hacking  cough,  progressive  emaciation,  haemoptysis  or  puru- 
lent sputa,  the  hectic  flush  and  the  night-sweats,  of  this  dread 
disease. 

SIGNS. 

The  signs  differ  in  various  stages  of  the  affection,  the  most 
important  being  :  diminished  movement  and  sinking  in  of  the 
chest-walls  in  the  infra-clavicular  region,  with  dulness  on  per- 
cussion ;  and  at  an  early  stage,  feeble  respiration,  or  subcrepi- 
tant  rales  confined  to  one  apex ;  followed  by  broncho-vesicular 
respiration,  exaggerated  vocal  resonance,  metallic  rales,  and 
the  signs  of  cavities. 

Phthisis  is  generally  described  as  having  three  stages,  but 
these  run  imperceptibly  into  each  other,  so  that  the  signs  of 
two  or  of  all  of  them  are  likely  to  be  combined  at  one  time 
in  the  same  individual.  The  stages,  therefore,  cannot  be 
sharply  delineated,  and  I  think  an  attempt  to  describe  the 
signs  of  each  separately  would  only  lead  to  confusion. 

The  stages  of  phthisis  consist  of,  first,  the  incipient  stage  ; 
second,  the  stage  of  more  complete  deposition,  occasioning 
consolidation  and  retraction ;  and  third,  the  stage  of  softening 
with  breaking  down  of  lung-tissue  and  the.  formation  of 
cavities.  The  pulmonary  lesions  occur  with  about  equal  fre- 

*  R.  E.  Thompson,  Physical  Examination  of  the  Chest. 


PULMONARY   PHTHISIS.  ,49 

quency  on  the  right  and  on  the  left  side  of  the  chest,  and  almost 
always  they  are  to  be  found  at  the  apex  of  the  lung. 

INSPECTION  AND  MENSURATION  yield  no  signs  in  the  early 
stage  of  this  disease,  except  increased  rapidity  of  the  respira- 
tory movements ;  but  after  a  few  weeks,  in  the  second  stage,  in 
addition  to  the  rapid  respirations,  we  observe  more  or  less  loss 
of  motion,  with  sinking  in  of  the  chest-wall  over  the  affected 
organ,  especially  during  deep  inspiration.  Later  on,  in  the 
last  stage  of  the  disease,  there  is  marked  emaciation,  with  pro- 
minence of  the  clavicles  due  to  the  sinking  in  of  the  tissues 
above  and  below  them  ;  loss  of  motion  becomes  more  distinct, 
and  there  is  depression  of  the  chest-walls,  usually  in  the  infra- 
clavicular  region. 

Exceptional. — In  exceptional  cases,  cavities  may  exist  in  the  apices  of  the  lungs  with- 
out any  considerable  depression  of  the  chest-walls  or  diminution  in  their  movements. 

PALPATION. — Early,  this  method  furnishes  no  signs.  As  soon 
as  any  considerable  amount  of  consolidation  has  taken  place, 
the  vocal  fremitus  is  likely  to  be  increased,  but  this  sign  is 
variable,  and  therefore  not  reliable.  Sometimes  gurgling 
fremitus  is  detected,  over  superficial  cavities. 

Exceptional. — Shrinking  of  the  affected  lung  may  drag  the  heart  a  short  distance 
from  its  normal  position,  as  indicated  by  the  site  of  its  apex  beat.  The  formation  of 
a  large  cavity  occasionally  causes  bulging  of  the  portion  of  the  chest  which  was 
formerly  depressed. 

PERCUSSION.— In  the  first  stage  of  this  disease,  there  is  slight 
dulness,  if  the  superficial  portions  of  the  lung  be  affected ;  but 
if  only  the  deeper  structures  are  involved,  this  sign  may  not 
be  obtained. 

Dulness,  when  slight,  is  best  obtained  with  the  patient's 
mouth  open,  and  the  difference  in  the  resonance  of  the  two 
sides  can  be  most  easily  recognized  at  the  end  of  a  full  inspira- 
tion.* In  this  connection,  it  must  be  constantly  borne  in  mind 
that  moderate  dulness  is-  frequently  a  normal  sign  over  the 
right  apex,  and.that  other  diseases  than  phthisis,  as,  for  example, 
bronchitis  and  circumscribed  pneumonia,  not  infrequently 
cause  temporary  dulness  in  the  infra-clavicular  region. 

*  Prof.  H.  A.  Johnson,  of  this  city,  informs  me  that  he  has  sometimes  obtained  e 
cellent  results,  in  obscure  cases,  by  listening  with  the  ordinary  binaural  steth 
the  chest-piece  of  which  is  held  by  the  patient  about  two  inches  in  front  of ! 
mouth,  while  percussion  is  being  made  on  the  chest. 


PULMONARY   DISEASES. 

Dulness  over  the  left  apex,  even  though  slight,  is  always 
abnormal,  and  when  persistent,  it  is  nearly  always  a  sign  of 
phthisis.  Marked  dulness,  if  persistent,  has  the  same  signifi- 
cance when  found  over  the  right  apex.  This  sign  is  sometimes 
found  behind,  when  it  cannot  be  detected  in  front.  It  is  fre. 
quently  present  in  the  supra-clavicular  or  in  the  clavicular 
region,  when  it  cannot  be  obtained  below  the  clavicle. 

Exceptional. In  the  first  stage  of  phthisis  the  resonance  is  sometimes  vesiculo- 

tympanitic,  on  account  of  secondary  circumscribed  emphysema. 

Consolidation  of  the  deeper  portions  of  the  lung  may  cause  no  dulness  upon  ordinary 
percussion,  if  healthy  lung  tissue  intervene  between  it  and  the  surface.  In  forcible 
percussion  a  small  amount  of  consolidation  at  the  surface  of  the  lung  may  be  over- 
looked, in  consequence  of  the  intense  resonance  from  the  deeper  tissues. 

It  should  be  remembered  in  estimating  the  amount  of  phthi- 
sical consolidation  that  the  degree  of  dulness  and  its  area 
may  be  due  to  the  consolidation  of  circumscribed  pneumonia, 
which  is  temporary.  The  extent  of  phthisical  consolidation  in 
such  cases  can  only  be  ascertained  after  the  inflammatory  pro- 
duct has  been  absorbed. 

In  the  second  stage  of  phthisis  dulness  becomes  very  marked, 
and  gradually  extends  over  a  wider  area,  owing  to  progressive 
consolidation  in  the  lung.  Up  to  this  time,  dulness  is  almost 
universally  confined  to  one  side.  At  the  same  time,  tubular — or 
according  to  Prof.  Flint  "  tympanitic "  -  resonance  may  be 
caused  by  the  bronchial  tubes  or  the  trachea,  especially  when 
percussion  is  made  near  the  borders  of  the  upper  part  of  the 
sternum. 

Exceptional. — In  this,  as  in  the  first  stage,  vesiculo-tympanitic  resonance  may  be 
obtained  in  rare  instances. 

In  the  third  stage,  dulness  is  obtained  over  the  affected  lung, 
unless  cavities  of  considerable  size  exist  near  the  surface.  In 
this  case,  the  resonance  over  a  limited  portion,  surrounded  bv 
dulness  and  corresponding  to  the  cavity,  may  be  tympanitic, 
amphoric,  or  "  cracked  pot "  in  character.  Sometimes  early 
in  the  morning  dulness  or  flatness  may  be  obtained  over  a 
cavity,  owing  to  its  being  filled  with  secretions,  which  will  give 
place,  after  free  expectoration,  to  the  signs  of  a  vomica.  In 
this  stage,  or  in  the  latter  part  of  the  second  stage,  dulness 
nearly  always  appears  at  the  apex  of  the  opposite  lung,  where 


PULMONARY    PHTHISIS.  j  -  r 

it  can  be  detected  by  comparing  the  resonance  over  the  dis- 
eased structure  with  that  below  the  second  or  third  rib. 

AUSCULTATION.— Among  the  first  signs  of  this  disease  to  be 
detected  by  this  method  are  feeble,  or  "  cog-wheel  "  respiration, 
with  subcrepitant  rales,  limited  to  a  small  portion  of  the  apex 
of  one  lung.  Occasionally  the  mucous  click  or  a  few  crepitant 
or  sibilant  rales,  or  crumpling  or  friction  sounds,  may  be  heard 
in  the  same  locality.  Broitcho-vesicular  respiration  is  obtained 
a  little  later.  The  heart-sounds  are  heard  with  abnormal  inten- 
sity over  the  affected  lung ;  if  the  consolidation  be  upon  the 
right  side,  the  first  sound  of  the  heart  will  be  most  distinct ;  if 
upon  the  left,  the  second  sound  is  more  intense  than  the  first. 

In  the  first  stage,  the  exaggerated  bronchial  whisper  is  a  sign 
of  considerable  value,  and  exaggerated  vocal  resonance  can 
usually  be  obtained. 

At  a  later  period,  in  the  second  stage,  broncho-vesicular  res- 
piration becomes  distinct,  the  respiratory  sounds  are  harsh  and 
tubular  in  quality,  and  the  expiratory  murmur  is  prolonged 
and  high-pitched.  There  are  also  large  and  small,  moist, 
crackling,  or  metallic  rales,  which  are  often  sticky  in  character, 
and  not  affected  by  coughing.  Friction  sounds  are  often  pres- 
ent, due  to  circumscribed  pleuritis,  caused  by  the  tubercular 
deposit  in  the  pleura.  In  a  few  cases,  subcrepitant  or  sibilant, 
and  occasionally  sonorous  rales,  may  still  be  heard  in  the  second 
stage,  limited  to  a  small  space  over  the  affected  tissue.  Rales 
are  generally  most  abundant  in  the  morning,  before  free  expec- 
toration has  taken  place.  Vocal  resonance,  with  the  whispered 
or  the  loud  voice,  is  now  exaggerated  or  bronchophonic.  In 
some  cases,  when  the  consolidated  lung  immediately  surrounds 
a  large  bronchial  tube,  pectoriloquy  may  be  obtained. 

During  the  latter  part  of  this  stage,  the  signs  of  incipient 
phthisis  usually  appear  at  the  apex  of  the  opposite  lung. 

In  the  third  stage,  when  cavities  have  formed  in  the  lungs, 
if  they  are  empty  and  are  connected  with  a  bronchial  tube, 
cavernous  or .  broncho-cavernous  respiration  will  be  detected. 
True  cavernous  respiration,  of  a  soft  blowing  or  puffing  charac- 
ter, and  of  low  pitch,  is  one  of  the  very  rare  signs  of  phthisis. 
Broncho-cavernous  respiration,  having  much  of  the  bronchial 
element,  still  with  a  hollow  quality  strongly  suggestive  of  a 
cavity,  is  heard  in  nearly  every  case.  Amphoric  respiration  is 


COLLEGE  OF  Ot^Tl-il 

l-K  \SICL,  lv£    C_    c.UUClZCKS 

LO  £     ,,  K  I*!-       I-  v-      II      v.-      /, 


.,„  PULMONARY   DISEASES. 

»5* 

found  in  exceptional  instances  only.  Associated  with  these 
signs  we  usually  hear  numerous  rales  and  gurgles  with  bronch- 
ophony,  pectoriloquy,  or  cavernous  voice,  and  occasionally 
metallic  tinkling  and  amphoric  voice.  The  signs  of  the  second 
stage  also  are  generally  present. 

If  cavities  are  filled  with  fluid,  none  of  the  ordinary  signs  of 
the  third  stage  may  be  obtained.  Small  cavities  located  in  the 
deeper  portions  of  the  lungs  are  not'easily  detected. 

In  advanced  phthisis,  we  may  reasonably  conclude  that  a 
cavity  exists  whenever  the  respiratory  and  vocal  sounds  over  a 
small  space,  and  limited  to  it,  are  peculiarly  intense  and  bron- 
chial in  character,  and  associated  with  metallic  rales. 

FIBROID   PHTHISIS. 

Synonyms. — Fibroid  degeneration  of  the  lungs ;  Fibrosis  ; 
Chronic  pneumonia;  Interstitial  pneumonia ;  Cirrhosis  or  Scir- 
rhus  of  the  lung ;  Induration  of  the  lung. 

This  disease  usually  results  from  the  extension  of  chronic 
inflammation  from  the  bronchial  mucous  membrane,  which 
causes  hyperplasia  of  the  intercellular  and  interlobular  con- 
nective tissues,  with  increase  in  the  substance  of  the  lung  and 
corresponding  diminution  of  its  air  cavities.  In  this  form  of 
phthisis,  there  is  no  exudation  into  the  air-cells  such  as  occurs 
in  croupous  pneumonia.  The  new-formed  tissue  at  length  con- 
solidates and  contracts,  forming  an  indurated  or  callous  tissue, 
less  in  bulk  than  the  original  healthy  lung  substance.  In  the 
mean  time  the  bronchial  tubes  often  become  dilated,  and  ulti- 
mately the  tissue  breaks  down,  with  or  without  the  deposition 
of  tubercle,  and  cavities  are  formed.  The  progress  of  this 
affection  is  not  so  rapid  as  that  of  the  more  common  form  of 
consumption,  but  its  symptoms  and  its  signs  are  usually  much 
the  same,  except  that  the  symptoms  do  not  appear  commen- 
surate to  the  pulmonary  lesions,  as  indicated  by  the  physical 
signs.  However,  in  well-marked  cases  the  signs  are  tolerably 
distinctive,  as  I  shall  presently  point  out. 

INSPECTION.— Flattening  of  the  chest-wall,  over  the  affected 
part,  and  depression  of  the  shoulder  are  observed. 

PALPATION. — Vocal  fremitus  is  exaggerated.  The  heart  is 
dislocated  more  or  less  toward  the  affected  side,  as  shown  by 
the  position  of  the  apex-beat. 

:-  J  J  G  G 

.     • 


MILIARY   OR   ACUTE   TUBERCULOSIS.: 


153 


PERCUSSION  gives  dulness  over  the  affected1  side.  Exag- 
gerated resonance  is  found  on  the  sound  side,  and  it  sometimes 
extends,  in  consequence  of  the  distention  of  the  healthy  lung, 
from  two  to  four  inches  beyond  the  median  line  upon  the  affected 
side. 

AUSCULTATION. — We  obtain  bronchial  breathing  and  bronch- 
ophony,  with  or  without  bronchial  rales.  The  vesicular  mur- 
mur is  feeble  or  absent. 


MILIARY   OR   ACUTE   TUBERCULOSIS. 

This   disease   is   attended   by  no   physical  signs  unless  the 
mucous  membrane  lining  the  air  passages  is  involved,  and  then 
there  are  no  signs  except  those  of  bronchitis.     The  diagnosis* 
in  such  cases  must  rest  upon  the  history  and  'symptoms,  and  the 
exclusion  of  other  pulmonary  affections. 

DIFFERENTIAL   DIAGNOSIS. 

Discrimination  between  the  various  forms  of  phthisis  is  often 
impossible,  and  is  always  attended  with  more  or  less  uncer- 
tainty. The  principal  features  which  are  supposed  to  be  of 
value  in  distinguishing  between  them  may  be  seen  in  the  fol- 
lowing table : 


FIBROID  AND  OTHER  VARIE- 
TIES OF  SIMPLE  INFLAM- 
MATORY PHTHISIS. 

The  constitutional  symp- 
toms come  on  slowly,  and 
are  less  severe  than  would 
naturally  be  expected  from 
the  condition  of  the  lung,  as 
indicated  by  physical  signs. 


CHRONIC  TUBERCULOSIS 
OR  THE  ORDINARY  FORM 
OF  PHTHISIS. 

History. 

The  constitutional  symp- 
toms come  on  more  rapidly, 
and  are  graver  than  would 
be  expected  from  the  phy- 
sical signs. 


The  fever  is  intermittent, 
with  an  afternoon  or  evening 
elevation  in  temperature  of 
from  one  to  two  degrees. 

Diarrhoea  is  not  common. 


Symptoms. 

The  fever  continues  with 
constant  elevation  of  tem- 
perature, but  no  marked 
exacerbations. 

Diarrhoea  usual. 


ACUTE  MILIARY  TUBERCU- 
LOSIS. 


The  disease  is  ushered  in 
with  chills  and  fever  without 
complete  remissions,  and 
there  is  rapid  accession  of 
grave  constitutional  symp- 
toms, which  cannot  be  ac- 
counted for  by  the  signs  of 
bronchitis,  which  are  the 
only  physical  signs  to  be  ob- 
tained. 

Fever  remittent,  temper- 
ature often  highest  in  the 
morning,  but  seldom  rising 
above  103^°  F. 


PULMONARY   DISEASES. 
T54 

Physical  Signs. 

Rapid  respiration,  and  Rapid  respiration,  physi-  Rapid  respiration,  with 
signs  of  consolidation  upon  cal  signs  of  consolidation  usually  the  signs  of  bronchi- 
palpation,  percussion,  and  less  marked  and  limited  to  tis,  and  ordinarily  no  signs 
auscultation,  usually  extend-  a  smaller  area  than  in  the  of  consolidation,  but  occa- 
ing  over  a  large  part  of  the  preceding  variety.  sionally  slight  dulness. 
lung. 

INFECTIVE   PHTHISIS. 

This  name  has  been  proposed  for  that  form  of  phthisis 
which  not  infrequently  affects  those  who  have  been  for  a  long 
time  exposed  to  the  exhalations  of  phthisical  patients.  Accord- 
ing to  Dr.  Thompson,  this  is  a  peculiar  condition,  simulating 
chronic  blood  poisoning,  in  which  the  general  disturbance  is 
*out  of  all  proportion  to  the  pulmonary  affection,  which  is  not 
established  until  some  months  afterward. 

SYMPTOMS. 

There  are  usually  present  depression,  loss  of  appetite,  inter- 
mittent chills,  emaciation,  night-sweats,  diarrhoea,  and  often 
vomiting,  and  late  in  the  disease,  cough. 

SIGNS. 

The  signs  are  said  to  differ  from  those  of  ordinary  phthisis 
in  being  entirely  insufficient  to  account  for  the  constitutional 
disturbance,  and  in  often  occurring  early  in  both  lungs.  The 
distinctive  signs,  if  there  be  any,  are  slight  instead  of  marked 
dulness,  and  -viscid  sub-crepitant  rales. 

DIAGNOSIS. 

The  diagnosis  will  rest  on  the  history  and  the  presence  of 
grave  symptoms,  which  cannot  be  adequately  accounted  for 
by  the  physical  signs. 

TREATMENT   OF   PHTHISIS. 

Pulmonary  phthisis,  whether  of  the  simple  inflammatory 
types,  catarrhal,  or  fibrous ;  or  whether  of  the  chronic  tuber- 
culous form,  or  of  the  acute  tuberculous  or  infective  varieties, 
requires  essentially  the  same  treatment.  However,  slight 
modifications  of  the  general  plan  are  advisable  when  the  lesions 
are  simply  of  an  inflammatory  character,  and  the  treatment  of 
acute  tuberculosis  can  seldom  or  never  be  more  than  palliative. 

The  most  important  remedies  in  the  treatment  of  this  disease 


INFECTIVE   PHTHISIS.  j-. 

are  alcohol,  cod-liver  oil,  chloride  of  calcium,  quinine,  and  iron, 
with  proper  climate. 

Alcohol  should  be  used  in  large  quantities,  as  much  as  can 
be  borne  without  being  felt  in  the  head,  providing  it  does  not 
derange  digestion  or  cause  elevation  of  temperature. 

Cod-liver  oil  should  be  given  to  those  patients  who  can  take 
it  without  disturbing  their  digestion,  in  doses  of  a  teaspoonful 
to  a  tablespoonful,  three  times  a  day.  They  should  always 
commence  with  small  doses.  Whenever  cod-liver  oil  cannot 
be  borne  it  may  be  substituted  by  cream  or  maltine.  The 
latter  is  usually  preferable  to  oil  during  warm  weather. 

Chloride  of  calcium  is  a  remedy  of  undoubted  value  in  many 
cases.  I  have  found  it  more  serviceable  than  the  hypophos- 
phites  of  calcium  or  sodium.  The  dose  is  from  ten  to  twenty, 
or  even  thirty  grains,  three  times  a  day.  I  usually  dissolve  it 
in  a  small  quantity  of  water,  and  combine  it  with  the  cod-liver 
oil.  By  shaking  the  bottle  before  the  medicine  is  poured  out, 
the  two  can  be  thoroughly  mixed.  It  may  be  added  to  an 
emulsion  of  cod-liver  oil  prepared  as  directed  in  Form.  4. 

Quinine  is  the  best  remedy  for  relieving  hectic  fever.  It 
will  usually  prove  efficient  when  given  in  the  same  manner  as 
for  intermittent  fever.  It  acts  most  promptly  when  given  in 
one  or  two  large  doses,  a  couple  of  hours  before  the  fever  is 
expected.  It  should  be  continued  in  this  manner  until  the 
temperature  falls  or  cinchonism  appears.  The  cases  in  which 
this  remedy  fails  to  check  the  fever  are  generally  considerably 
benefited  by  it. 

Iron  is  a  valuable  remedy  in  this  disease,  but  it  must  not  be 
given  when  there  is  much  fever,  for  it  aggravates  this  symptom. 

Belladonna  is  the  best  remedy  for  checking  the  night-sweats. 
Six  minims  of  the  tincture  of  belladonna,  or  the  one  hundred 
and  twentieth  of  a  grain  of  atropia,  at  bed  time,  is  sufficient  in 
the  majority  of  cases,  but  the  dose  may  be  increased  to  twice 
this  amount,  and  repeated  two  or  three  times  daily  if  necessary. 

Tonic  doses  of  the  bichloride  of  mercury— gr.  ^-jV,— will 
be  found  beneficial  in  some  cases,  especially  those  of  a  chronic 
catarrhal  or  fibroid  character.  The  same  may  be  said  of  arsenic, 
but  this  must  not  be  given  when  there  is  much  fever. 

When  there  is  a  suspicion  of  syphilitic  origin  of  the  disease, 
iodide  of  potassium  should  be  tried. 


isg  PULMONARY   DISEASES. 

Sedative  troches  (Form.  21-24)  and  sedative  inhalations  of 
benzoin,  opium,  or  chloroform  are  useful  in  allaying  the  cough 

(Form.  34-40). 

Stimulant  inhalations  are  frequently  serviceable  in  the  early 
stages  of  the  inflammatory  varieties  of  the  disease,  but  they 
are  likely  to  do  harm  when  there  are  tubercular  deposits.  For 
this  purpose,  iodine,  carbolic  acid,  creasote,  or  oil  of  white 
pine,  are  most  frequently  used  (Form.  43,  49,  50,  57,  80). 

Cough  mixtures  are  necessary  especially  late  in  the  disease, 
but  they  should  be  given  as  sparingly  as  possible.  Of  these 
perhaps  the  most  serviceable  consists  of  morphia  and  carbonate 
of  ammonium  (Form.  5).  Sedative  troches  and  inhalations  are 
preferable  to  cough  mixtures  when  they  will  answer  the  pur- 
pose. 

The  neuralgic  pains  which  often  trouble  phthisical  patients 
are  best  prevented  by  regular  and  vigorous  frictions  of  the  sur- 
face with  a  coarse  towel.  When  severe,  they  are  usually 
promptly  relieved  by  hot  applications  to  the  surface.  These 
applications  should  be  as  hot  as  can  be  borne  and  should  be 
frequently  repeated  until  pain  subsides. 

Counter-irritation  is  useful  especially  in  cases  of  an  inflam- 
matory character,  that  is,  those  cases  growing  out  of  pneu- 
monia, bronchitis,  or  pleuritis,  before  tubercles  have  been 
deposited. 

I  frequently  employ  for  this  purpose  an  ointment  composed 
of  tartar  emetic,  croton  oil,  cantharides,  stramonium,  and  cam- 
phor (Form.  6).  It  is  an  effectual  and  almost  painless  counter- 
irritant.  Burgundy  pitch  plasters,  croton  oil,  iodine  or  blisters 
may  be  used  for  the  same  purpose. 

The  digestive  functions  must  receive  careful  attention. 
Nutritious  and  easily  digestible  diet  of  varied  character  should 
be  ordered. 

Climate. — Change  of  climate  is  often  the  most  efficient 
remedy  in  these  cases,  especially  in  the  early  stage  of  the 
disease.  As  a  rule,  a  warm  dry  atmosphere  should  be  selected, 
but  this  will  not  be  best  for  all  patients.  Those  whose 
former  experience  shows  that  they  have  felt  best  in  cold 
weather  should  be  sent  to  northern  regions.  Those  who  feel 
best  in  warm  weather  will  do  best  in  southern  latitudes.  A  few 
persons  feel  best  in  a  damp  atmosphere,  but  this  must  be  con- 


BROWN  INDURATION  OF  THE  LUNG.          j*~ 

sidered  as  an  exception  to  the  rule.  A  few  questions  will  gen- 
erally enable  the  physician,  in  individual  cases,  to  decide  upon 
the  climate  to  be  recommended. 

A  high  altitude  is  generally  most  beneficial  in  the  early 
stages  of  the  disease,  but  later,  moderate  elevations  are  better. 

For  a  cool,  dry  climate  with  moderate  elevation,  patients 
may  be  sent  into  the  northern  part  of  Minnesota  or  of  Dakota. 
For  a  warm  dry  climate,  with  moderate  elevation,  inland  por- 
tions of  Southern  California,  the  Western  portion  of  Texas  or 
certain  parts  of  Kansas,  Tennessee,  Georgia  and  South  Caro- 
lina will  be  found  beneficial.  Colorado  and  Wyoming  Terri- 
tory afford  the  most  suitable  places  of  abode  for  those  who 
require  a  dry  or  mild  climate  with  high  altitude.  Mild 
moist  atmospheres  at  low  or  moderate  elevations  are  found  in 
Cuba,  the  Bahama  or  Bermuda  islands  or  on  the  Eastern  Coast 
of  Florida.  Long  sea-voyages  are  sometimes  useful  in  the 
first  stage  of  the  disease.  Whatever  climate  is  sought,  it  is.  of 
the  highest  importance  for  patients  to  be  able  to  take  daily  out- 
door exercise,  to  breathe  a  pure  atmosphere  night  and  day,  to 
be  protected  from  all  causes  of  colds  and  to  be  supplied  with 
nutritious  diet.  Patients  in  the  later  stages  of  the  disease 
usually  live  most  comfortably  in  warm  climates  at  low  altitudes, 
but  they  should  not  be  sent  away  from  friends  and  the  com- 
forts of  a  home  to  die  among  strangers  and  the  gloomy  sur- 
roundings of  a  health  resort. 

BROWN  INDURATION  OF  THE  LUNG. 
This  affection,  which  seems  to  arise  from  a  varicose  condition 
of  the  pulmonary  veins,  is  generally  dependent  on  disease  of 
the  mitral  valves.  It  consists  of  induration  of  considerable 
portions  of  the  lungs,  usually  radiating  from  the  main  bronchi. 
The  blood-vessels  are  swollen  and  tortuous,  the  alveolar  walls 
are  swollen,  and  the  air-vesicles  are  partially  filled  with  cells 
and  blood  pigment. 

SYMPTOMS. 

The  symptoms  are  those  of  cardiac  disease,  with  cough  and 
haemoptysis. 

SIGNS. 

The  principal  sign  is  dulness,  limited  mostly  to  the  second 
intercostal  space  near  the  sternum. 


j-g  PULMONARY   DISEASES. 

INSPECTION  and  MENSURATION  yield  no  signs. 

PALPATION. — Exaggerated  vocal  resonance  is  almost  always 
obtained. 

PERCUSSION  gives  dulness,  especially  in  the  regions  near  the 
main  bronchi. 

AUSCULTATION  reveals  broncho-vesicular  or  bronchial  respi- 
ration, and-bronchophony,  with  occasionally  pectoriloquy. 

DIFFERENTIAL   DIAGNOSIS. 

This  affection  may  be  distinguished  from  other  pulmonary 
diseases  causing  consolidation  by  the  position  of  the  dulness 
and  by  the  presence  of  the  signs  of  cardiac  disease. 

TREATMENT. 

The  principal  treatment  consists  of  such  measures  as  will 
most  effectually  relieve  the  heart  disease  which  causes  this 
affection.  Carbonate  or  chloride  of  ammonium  and  moderate 
doses  of  digitalis  are  specially  indicated.  Alcoholic  stimulants 
may  also  be  found  useful.  Counter-irritants,  such  as  cupping 
and  iodine,  are  sometimes  beneficial. 

SYPHILITIC   DISEASES   OF   THE   LUNGS. 

It  is  a  well-recognized  fact  that  syphilis  causes  tubercular 
disease  of  the  lungs,  the  signs  of  which  in  no  way  differ  from 
those  of  ordinary  phthisis.  Cases  are  occasionally  observed  in 
which  a  specific  form  of  bronchitis,  or  gummata  occur  as  a 
result  of  the  venereal  taint. 

The  signs  of  syphilitic  bronchitis  are  the  same  as  those  of 
the  non-specific  affection.  A  distinction  between  the  two  can 
only  be  made  by  attention  to  the  history  and  the  attendant 
symptoms. 

DIFFERENTIAL    DIAGNOSIS. 

The  differential  diagnosis  between  syphilitic  disease  of  the 
pulmonary  parenchyma  and  phthisis  is  extremely  difficult,  and 
often  impossible.  But  when  uncomplicated,  pulmonary  syphilis 
usually  differs  from  phthisis,  as  shown  in  the  following  table : 

SYPHILITIC  DISEASE  OF  THE  LUNGS.  PHTHISIS. 

History  and  Symptoms. 

The  history  of  syphilis  ;  thickening  of  No  history  of  syphilis;  no  thickening  of 

the  periosteum  and    perichondrium  over         the  periosteum  or  perichondrium  over  the 
the  inner  end  of  the  clavicles,  and  one  or         clavicles  or  cartilages  of  the  upper  ribs, 


HYDATIDS   OF   THE   LUNGS.  I59 

more  of  the  cartilages  of  the  upper  ribs,         and   no  sub-sternal   tenderness.     Hectic 
with  sub-sternal  tenderness  on   pressure         fever  and  marked  emaciation  always  pres- 
over  the  upper  part  of  the  sternum.    Usu-         ent,  with  usually  haemoptysis. 
ally  neither  fever  nor  decided  emaciation, 
and  no  haemoptysis. 

Physical  Signs. 

Dulness  over  the  nodules,  usually  con-  Dulness  usually  at  the  apex,  and  grad- 

fined  to  one  lung,  and  found  at  its  base  or         ually    extending    over    the    surrounding 
at  the  lower  part  of  the  upper  lobe.     The         lung, 
dulness   remaining    circumscribed   for   a 
long  time.     Viscid  subcrepitant  rales,  or 
several    mucous   clicks,    diffused   over   a 
considerable  portion  of  the  lung,  are  be- 
lieved to  be  one  of  the  earliest  indications 
of  the  syphilitic  affection;  later  the  aus- 
cultatory  signs .  are  the  same  as  those  of 
phthisis. 

TREATMENT. 

Antisyphilitic  constitutional  remedies,  such  as  iodine,  iodide 
of  potassium,  or  small  doses  of  the  bichloride  of  mercury,  are 
indicated.  We  should  also  employ  tonic  and  supporting  meas- 
ures, similar  to  those  recommended  in  pulmonary  phthisis. 

HYDATIDS   OF   THE   LUNGS. 

This  is  a  rare  affection,  which  presents  symptoms  and  signs 
similar  to  those  of  phthisis.  The  cyst  most  frequently  occupies 
the  right  lung.  Commencing  within  the  lung  it  gradually 
enlarges,  and  compresses  the  pulmonary  tissues  about  it. 

SYMPTOMS. 

The  symptoms  are  like  those  of  phthisis,  viz.,  emaciation, 
night-sweats,  cough,  dyspnoea,  and  expectoration  of  bloody 
and  purulent  sputa.  Finally,  hydatid  cysts,  or  portions  of  them, 
and  the  hooklets  of  the  echinococci  are  thrown  off. 

SIGNS. 

The  principal  signs  are :  bulging  and  loss  of  motion  of  the 
side,  nodular  prominences  in  the  intercostal  spaces,  and  when 
the  cysts  approach  the  surface  of  the  lung,  dulness  or  flatness 
on  percussion,  and  suppressed  respiration  or  tubular  breathing. 
A  positive  diagnosis  can  seldom  be  made  until  the  hooklets  of 
the  "  echinococcus  hominis "  are  discovered  in  the  sputum. 
This  does  not  occur  until  late  in  the  disease,  when,  after  death 
of  the  entozoon,  it  begins  to  be  ejected  from  the  body. 


l6o  PULMONARY   DISEASES. 

According  to  Dr.  Bird,  the  diagnosis  may  be  made  with  a 
fair  degree  of  certainty  early  in  the  disease,  if  the  cyst  is  of  any 
considerable  size  and  impinges  against  the  chest-wall.  In  such 
cases  the  following  signs  have  been  noticed  : 

INSPECTION  AND  MENSURATION. — Decubitus  is  always  on 
the  sound  side.  The  respiratory  movements  of  the  affected  side 
are  deficient,  and  there  may  be  slight  bulging  in  one  or  more 
places,  forming  irregular  nodular  swellings  in  the  intercostal 
spaces,  over  the  cysts ;  which  are  usually  found  in  the  axillary 
or  infra-clavicular  regions. 

PALPATION. — Vocal  fremitus  may  be  absent,  and  fluctuation 
can  sometimes  be  detected  over  the  cyst. 

PERCUSSION. — Flatness  is  found  over  a  limited  area  corre- 
sponding to  the  cyst.  In  order  to  be  of  value  in  diagnosis  this 
area  of  flatness  should  not  be  less  than  three  or  four  inches  in 
diameter.  It  should  have  a  rounded  outline,  and  it  must  be 
clearly  separated  by  a  line  of  demarcation  from  the  surround- 
ing resonance. 

AUSCULTATION. — There  is  absence  of  the  respiratory  mur- 
mur over  the  area  of  flatness,  and  normal  respiration  around  it, 
immediately  beyond  the  line  of  demarcation.  The  compressed 
lung  close  about  the  cyst  may  cause  a  more  or  less  tubular 
sound. 

DIFFERENTIAL   DIAGNOSIS. 

This  affection  is  liable  to  be  mistaken  for  phthisis  or  circum- 
scribed pleurisy ;  and,  as  already  stated,  a  positive  diagnosis 
cannot  often  be  made  until  the  hooklets  of  the  echinococci  are 
found.  Attention  to  the  differential  characters  noted  in  the 
following  table  will  aid  in  making  the  diagnosis. 

HYDATIDS  OF  THE  LUNGS.  PHTHISIS. 

Inspection. 
Prominence  of  the  intercostal  spaces.  No  prominence  of  the  intercostal  spaces. 

Palpation. 

Absence  of  fremitus,  and  perhaps  flue-  Exaggerated  vocal  fremitus;  no  fluctua- 

tuation  over  the  cyst.  tion  over  the  consolidated  lung. 

Percussion. 

Flatness  over  the  cyst  sharply  defined  Dulness  over  consolidated  lung,  grad- 

by  a  line  of  demarcation  from  the  reso-         ually  fading  off  into  normal  resonance. 
nance  of  the  surrounding  healthy  struct- 
ure. 


HYDATIDS   OF   THE   LUNGS.  jgj 

A  uscultation. 

Absence   of   respiratory   murmur   over  Broncho-vesicular  respiration,  or  caver- 

cyst  (flat  area).  nous  signs  over  dull  area. 

The  distinctive  features  between  this  disease  and  pleurisy 
are  as  follows : 

HYDATIDS  OF  THE  LUNGS.  CIRCUMSCRIBED  PLEURISY. 

History. 

Usually  located  in  the  infra-clavicular  Usually  located  at  the  base  of  the  chest, 

or  axillary  regions. 

Symptoms  and  Signs. 

Gradual  accession  of  the  local  and  con-  Usually  ushered  in  with  acute  febrile 

stitutional  symptoms.  symptoms. 

Inspection. 

Nodular    prominence     of    intercostal  Uniform    prominence    of    intercostal 

spaces.  spaces. 

Percussion  and  Auscultation. 

Signs  usually  in  the  upper  part  of  the  Signs  generally  in  the  lower  part  of  the. 

chest.  .     chest. 

TREATMENT. 

As  the  disease  can  seldom  be  distinguished  from  phthisis,  the- 
treatment  must  generally  be  the  same  as  for  the  latter.  In  those 
cases  where  the  disease  can  be  positively  diagnosticated,  aspi- 
ration of  the  cyst  and  injection  with  iodine  is  the  most  rational 
treatment  (Form.  7). 


ii 


THE  HEART  AND  AORTA. 


LECTURE  XV. 

ANATOMY,  RELATIONS,   AND  PHYSIOLOGY. 

A  knowledge  of  the  anatomy  and  physiology  of  the  heart  is 
so  essential  in  making  a  correct  diagnosis,  that  before  pro- 
ceeding to  the  consideration  of  the  means  for  detecting  its 
diseases  I  will  direct  your  attention  briefly  to  the  normal  con- 
ditions of  the  organ. 

The  heart  is  a  hollow  muscle  of  a  conical  form,  which  may 
be  termed  the  centre  of  the  circulatory  system.  Its  function 
is  to  distribute  blood  throughout  the  entire  body. 

The  heart  is  held  in  position  by  means  of  the  large  blood- 
vessels springing  from  its  base,  and  it  is  enclosed  in  a  fibro- 
serous  sac  which  is  so  attached  to  the  diaphragm  and  great 
vessels  as  to  prevent  the  organ  from  rolling  about  in  the  chest. 

The  heart  is  located  near  the  central  portion  of  the  chest, 
sheltered  in  front  by  the  sternum ;  posteriorly  it  is  protected 
by  the  thick  chest-walls,  and  by  the  spinal  column ;  and  later- 
ally it  is  guarded  from  all  shocks  by  those  soft  air-cushions, 
the  lungs.  It  is  placed  with  its  long  axis  obliquely  to  the 
perpendicular  axis  of  the  chest,  so  that  the  base  is  directed 
upward,  outward,  and  backward,  toward  the  right  shoulder  ; 
and  the  apex  downward  and  forward. 

The  pericardium  which  envelops  this  organ  is  a  fibro-serous 
sac,  the  external  layer  of  which  is  fibrous  and  the  internal 
serous.  The  external  layer  encloses  the  arteries  for  about  two 
inches  from  the  base  of  the  heart,  and  is  continuous  with  their 
external  covering.  From  this  point  it  passes  downward  about 
the  sides  of  the  heart  to  be  attached  to  the  diaphragm.  The 
serous  portion  of  the  pericardium  envelops  the  heart  com- 
pletely, ancfr covers  the  blood-vessels  springing  from  its  base  for 
about  two  inches.  It  is  then  reflected  upon  the  inner  surface 


ANATOMY  AND   PHYSIOLOGY.  l6 

of  the  fibrous  layer,  and  passing  downward  it  finally  covers 
the  upper  surface  of  the  diaphragm,  beneath  the  heart,  thus 
forming  a  closed  sac  similar  to  that  surrounding  the  'lung. 
The  two  surfaces  of  the  pericardium  are  constantly  in  apposi- 
tion during  health.  They  are  moistened  by  thin  serum,  which 
prevents  any  friction  during  the  action  of  the  heart.  The 
pericardium  extends  from  the  level  of  the  second  to  that  of  the 
seventh  left  costal  cartilage.  It  is  farther  from  the  chest-walls 
superiorly  than  inferiorly. 

The  heart,  with  its  overlying  pericardium,  is  in  relation : 
anteriorly,  with  the  anterior  border  of  the  lungs  and  with  a 
small  portion  of  the  thoracic  walls,  from  which  it  is  separated 
by  a  small  amount  of  areolar  tissue ;  laterally,  with  the  lungs 
covered  by  the  pleurae ;  and  posteriorly,  upon  each  side,  with 
the  lungs  and  pleurae.  In  the  middle  line  posteriorly  this 
organ  lies  near  the  spinal  column,  from  which  it  is  separated 
by  cellular  tissue  and  the  aorta  and  oesophagus. 

The  heart  is  about  the  size  of  its  owner's  fist,  averaging  in 
weight  about  ten  ounces.  In  females  it  ranges  from  eight  to 
ten  ounces,  in  males  from  ten  to  twelve.  The  anterior  surface 
of  the  organ  is  convex ;  the  posterior  surface  is  flattened ;  the 
right  border  is  long,  thin,  and  sharp,  and  the  left  border,  short, 
thick,  and  rounded.  Running  longitudinally  about  the  heart  is 
a  well-defined  fissure,  which  is  found  upon  the  anterior  surface, 
within  half  or  three  quarters  of  an  inch  of  the  left  border  of 
the  organ,  and  on  the  posterior  surface,  a  similar  distance  from 
the  right  border.  This  fissure  lodges  the  coronary  arteries, 
which  supply  the  heart  with  blood;  and  it  indicates  the  posi- 
tion of  the  septum,  which  divides  the  right  side  of  the  heart 
from  the  left.  Near  the  base  of  the  heart  is  found  a  transverse 
fissure,  which,  however,  is  deficient  in  front  on  account  of  the 
origin  of  the  pulmonary  artery  in  that  position.  This  fissure 
indicates  the  position  of  the  septum  between  the  cavities  at 
the  base  and  the  cavities  at  the  apex  of  the  heart. 

CAVITIES  of  THE  HEART. — By  these  septa,  the  heart  is 
divided  into  four  cavities.  Those  at  the  base  are  known  as  the 
auricles,  one  of  which  belongs  to  the  right  and  the  other  to 
the  left  side  of  the  heart.  Those  at  the  apex  are  known  as  the 
right  and  left  ventricles.  These  cavities  are  of  nearly  equal 
size,  each  being  capable  of  containing  about  two  ounces.  The 


£  THE   HEART   AND  AORTA. 

walls  of  the  cavities  upon  the  right  side  are  thinner  than  those 
upon  the  left,  because  their  work  is  easier;  and  the  walls  of  the 
auricles  are  much  thinner  than  those  of  the  ventricles. 

The  right  auricle  receives  the  blood  from  the  venous  system, 
through  the  ascending  and  descending  -venae  cavae  ;  and  trans- 
mits it  through  the  auriculo-ventricular  opening,  into  the  right 
ventricle,  which  contracting  forces  the  blood  onward  through 
the  pulmonary  artery  into  the  lungs.  The  left  auricle  receives 
the  blood  from  the  pulmonary  veins,  and  transmits  it  to  the 
left  ventricle,  whence  it  is  distributed,  by  the  aorta  and  its 
branches,  throughout  the  entire  body. 

VALVES.— The  internal  surface  of  the  heart  is  lined  by  a 
glistening  membrane,  known  as  the  endocardium,  folds  of 
which  at  the  various  orifices  constitute  the  valves.  At  the 
orifice  between  the  right  auricle  and  the  right  ventricle,  we 
find  three  valves  which  are  named  the  tricuspid.  At  the  orifice 
of  the  pulmonary  artery  are  three  valves  known  as  the  pul- 
monary semilunar  valves.  At  the  aorta  we  have  a  similar 
number,  called  the  aortic  semi-lunar  valves.  At  the  orifice 
between  the  left  auricle  and  ventricle  are  two  folds  known  as 
the  mitral  valves. 

RELATIONS  OF  THE  HEART  TO  THE  SURFACE. 

The  greater  portion  of  the  heart  lies  beneath  the  lower  part 
of  the  sternum,  but  the  right  auricle,  and  a  small  part  of  the 
right  ventricle,  extend  from  one  half  to  three  fourths  of  an 
inch  to  the  right  of  the  sternum ;  and  the  ventricles  extend 
about  two  inches  to  the  left  of  this  bone  (Fig.  I,  page  3). 

The  auricles  are  on  a  line  with  the  third  ribs,  the  right  auricle 
extending  considerably  beyond  the  sternum  into  the  third 
interspace  upon  the  right  side,  and  the  left  being  located 
beneath  the  third  left  costal  cartilage  and  intercostal  space. 
The  left  ventricle  lies  mainly  beneath  the  right ;  that  part  of 
it  which  is  superficial  is  found  entirely  to  the  left  of  the  ster- 
num. The  greater  portion  of  the  right  ventricle  lies  beneath 
the  lower  part  of  the  sternum ;  but  a  small  part  of  it,  at  the 
base,  extends  to  the  right  of  the  sternum,  and  its  apex  is  found 
to  the  left  of  this  bone,  in  the  triangular  space  existing  between 
the  sternum  and  the  margin  of  the  left  lung.  The  base  of  the 


ANATOMY  AND   PHYSIOLOGY.  ,65 

heart  extends  to  the  upper  margin  of  the  third  rib,  and  its  apex 
to  the  space  between  the  fifth  and  sixth  ribs,  about  half  an  inch 
within  the  mammillary  line,  and  two  or  two  and  a  half  inches  to 
the  left  of  the  sternum.  The  position  of  the  apex  is  not  exactly 
constant,  as  it  changes  more  or  less  with  the  respiratory  move- 
ments and  the  position  of  the  patient.  It  is  said  that  the  apex 
may  move  as  much  as  an  inch  and  a  half  from  left  to  right,  or 
•vice  versa,  when  the  patient  lies  on  the  right  or  the  left  side ; 
and  a  few  cases  have  been  reported  in  which  prolonged  decu- 
bitus  on  one  side  seems  to  have  caused  permanent  dislocation 
of  the  heart. 

From  the  base  to  the  apex  of  the  heart,  in  a  vertical  line,  the 
distance  is  about  five  inches.  Measuring  from  the  mesosternal 
line  to  the  left,  the  heart  extends  over  the  third  rib  from  two 
and  one  half  to  three  inches,  over  the  fourth  rib  three  and  one 
half  to  four  inches,  and  in  the  fifth  interspace  from  three  to 
three  and  one  half  inches.  Posteriorly,  the  base  of  the  heart 
corresponds  to  the  sixth  and  seventh  dorsal  vertebrae. 

POSITION  OF  THE  VALVES. — The  relation  of  the  valves  to 
the  surface  of  the  chest  may  be  ascertained  by  passing  needles 
through  the  chest-walls  of  the  cadaver  before  the  thorax  is 
opened.  In  this  manner  it  has  been  ascertained  that  the  pul- 
monary valves  lie  beneath  the  junction  of  the  third  costal 
cartilage  of  the  left  side  with  the  sternum.  The  mitral  valves 
lie  close  to  the  left  border  of  the  sternum  in  the  third  inter- 
costal space.  The  tricuspid  valves  lie  in  front  of  the  mitral, 
near  the  middle  of  the  sternum,  on  a  line  with  the  fourth  ribs. 
The  aortic  valves  lie  beneath  the  sternum,  just  below  the  level 
of  the  third  ribs,  and  a  little  to  the  left  of  the  median  line  (Fig. 
i,  page  3).  It  will  be  seen  from  this  that  a  circle  of  not  more 
than  an  inch  in  diameter,  with  its  centre  at  the  left  edge  of  the 
sternum  in  the  third  intercostal  space,  will  include  the  greater 
portion  of  all  of  these  valves. 

The  discrepancy  noticeable  in  the  description,  by  different 
authors,  of  the  position  of  the  valves  is  doubtless  due,  in  the 
main,  to  their  being  located  after  the  thorax  has  been  opened, 
when  the  collapse  of  the  lungs  will  have  more  or  less  displaced 
the  heart. 

AORTA.— The  aorta  springs  from  the  base  of  the  left  ven- 
tricle, and  passes  upward,  forward,  and  to  the  right,  to  the 


THE   HEART  AND  AORTA. 

second  intercostal  space,  where  it  is  more  superficial  than  in 
any  other  part  of  its  course.  In  this  situation,  it  is  within  the 
pericardial  sac.  From  this  point,  it  passes  backward,  upward, 
and  to  the  left;  and  it  finally  passes  downward,  bending  com- 
pletely upon  itself,  so  as  to  rest  along  the  left  side  of  the  fifth 
and  sixth  dorsal  vertebrae.  The  highest  portion  of  the  arch 
is  on  a  line  with  the  first  costo-sternal  articulation. 

PULMONARY  ARTERY.— The  pulmonary  artery  rises  from 
the  base  of  the  right  ventricle,  beneath  the  third  costal  carti- 
lage at  its  junction  with  the  sternum,  and  passes  upward  and 
outward,  about  two  inches,  to  the  second  costal  cartilage, 
where  it  bifurcates ;  one  of  the  branches  going  to  each  lung. 
It  will  be  seen  that  the  aorta  may  be  found  close  to  the  margin 
of  the  sternum  in  the  second  intercostal  space  upon  the  right 
side,  and  the  pulmonary  artery  in  a  similar  position  on  the 
left. 

PHYSIOLOGICAL  ACTION   OF   THE   HEART. 

In  health,  the  heart  performs  the  part  of  a  perfect  automatic 
engine,  the  strokes  of  which  follow  each  other  in  regular  suc- 
cession, without  stopping,  from  foetal  life  until  the  moment  of 
death. 

The  pulsations  of  the  heart  consist,  first,  of  contraction,  then 
dilatation  of  its  walls ;  which  acts  are  followed  by  a  short  period 
of  rest  These  pulsations  occur  in  the  adult,  from  seventy  to 
eighty  times  per  minute.  While  they  are  taking  place,  the 
blood  is  flowing  from  the  auricles  into  the  ventricles,  and  from 
these  on  into  the  arteries,  and  the  valves  guarding  the  orifices 
of  the  heart  are  opening  and  closing  synchronously  with  its 
contraction  and  dilatation  (Figs.  28  and  29,  pages  196,  197). 

HEART-SOUNDS. — With  the  closure  of  the  mitral  and  tricus- 
pid  valves,  a  sound  is  heard,  which  is  known  as  the  first  sound 
of  the  heart.  With  the  closure  of  the  semilunar  valves,  a 
shorter  and  sharper  sound  is  obtained,  which  is  termed  the 
second  sound.  The  contraction  of  the  heart  is  known  as  its 
systole  ;  the  dilatation,  as  its  diastole. 

The  cardiac  pulsation  begins  with  contraction  of  the  auri- 
cles, which  occupies  about  one  eighth  of  the  period  of  a  com- 
plete pulsation.  While  this  is  taking  place,  the  blood  is  flow- 
ing in  a  full  stream  through  the  auriculo-ventricular  openings 


PHYSIOLOGICAL  ACTION   OF   THE   HEART.  ^7 

into  the  ventricles,  and  the  mitral  and  tricuspid  valves  float  out 
upon  the  current,  causing  no  obstruction  (Fig.  28,  page  196). 

The  systole  of  the  auricles  is  followed  immediately  by  their 
diastole,  which  is  a  purely  passive  movement,  continuing  from 
the  end  of  the  systole  to  the  beginning  of  the  next  pulsation, 
thus  occupying  seven  eighths  of  the  time  of  a  complete  cardiac 
pulsation.  During  the  diastole  of  the  auricles,  the  blood  is 
again  filling  them  from  the  venae  cavse  and  pulmonary  veins. 
The  contraction  of  the  cardiac  muscular  fibres  passes  with  a 
wavy  motion  from  the  auricles  to  the  ventricles,  so  that  the 
ventricular  systole  immediately  follows  that  of  the  auricles. 

During  the  systole  of  the  ventricles,  the  vertical  diameter  of 
the  heart  is  shortened  ;  the  apex  approximates  more  nearly  to 
the  base ;  and  at  the  same  time  it  describes  a  spiral  motion 
from  left  to  right  and  from  behind  forward,  striking  against 
the  chest-wall  between  the  fifth  and  sixth  ribs,  where  its  im- 
pulse may  usually  be  seen  and  felt. 

With  this  contraction  there  is  sudden  closure  of  the  mitral 
and  the  tricuspid  valves.  The  semilunar  valves  being  thrown 
open  by  the  current,  the  blood  is  carried  onward  into  the 
aorta  and  the  pulmonary  artery  (Fig.  29,  page  197).  The 
time  occupied  by  the  systole  of  the  ventricles  is  about  three 
eighths  of  a  complete  pulsation.  With  the  closure  of  the 
mitral  and  tricuspid  valves,  we  may  hear  the  first  sound  of  the 
heart. 

The  ventricular  diastole  follows  immediately  after  their  sys- 
tole. The  elastic  tissue  of  the  arteries  contracts,  and  a  portion 
of  the  blood  is  forced  backward  toward  the  heart,  which  it  is 
prevented  from  entering  by  the  abrupt  closure  of  the  semilunar 
valves  that  guard  the  aortic  and  pulmonary  orifices. 

With  the  diastole  of  the  ventricles,  the  heart  assumes  its 
former  shape  and  position  ;  the  auriculo-ventricular  valves  open, 
and  blood  flows  passively  into  the  ventricles.  This  occupies 
about  two  eighths  of  the  period  of  a  complete  cardiac  pulsation. 

Closure  of  the  semilunar  valves  produces  the  second  sound 
of  the  heart,  which  is,  therefore,  caused  by  the  contraction  of 
the  arteries. 

The  diastole  of  the  ventricles  is  followed  by  a  period  of 
resfc  which  occupies  about  two  eighths  of  the  time  for  a  com- 
plete pulsation. 


i68 


THE   HEART   AND   AORTA. 


During  this  period,  the  blood  continues  to  flow  from  the  auri- 
cles into  the  ventricles,  so  that,  at  the  instant  just  preceding 
another  pulsation,  all  of  the  cavities  of  the  heart  are  full,  but 
not  distended.  With  the  contraction  of  the  auricles,  the  ven- 
tricles are  distended  by  an  additional  amount  of  blood,  but 
probably  the  auricles  are  not  completely  emptied.  The  dis- 
tention  of  the  ventricles,  caused  by  the  systole  of  the  auricles, 
excites  their  contraction,  and  thus  the  blood  is  forced  onward 
into  the  arteries.  If  the  cycle  of  time  taken  up  by  a  cardiac 
pulsation  were  divided  into  five  equal  parts,  about  one  fifth 
would  be  occupied  by  the  systole  of  the  auricles,  two  fifths 
by  the  systole  of  the  ventricles,  and  two  fifths  by  the  diastole 
of  the  ventricles  and  the  period  of  repose.  The  physiological 
action  of  the  heart  is  graphically  represented  by  a  modifica- 
tion of  Dr.  Gairdner's  diagram  (Fig.  24). 


TIBIAL'PULU  HMIAL  PULSC 

FIG.  24. — Physiological  Action  of  the  Heart  (altered  slightly  from  Balfour). 

In  this  diagram,  the  inner  circle  represents  the  physiolog- 
ical action  of  the  heart,  apart  from  any  manifest  signs. 

The  outer  circle  represents  the  external  manifestations  of 
the  heart's  action ;  the  ring  between  the  circles  illustrates  the 
sounds  and  periods  of  silence,  and  outside  of  the  outer  circle, 
the  arc  6f  a  third  circle  represents  the  impulse  of  the  apex 
against  the  chest-wall.  Lines  radiating  from  the  centre  repre- 
sent the  pulse  in  the  neck,  wrist,  and  ankle. 

As  seen  by  the  diagram,  the  systole  of  the  auricles  gives  rise 
to  no  external  manifestations,  but  with  the  beginning  of  the 
ventricular  systole  we  appreciate  the  first  sound  of  the  heart, 
as  indicated  by  the  shading  of  the  ring  between  the  two  circles ; 


PHYSIOLOGICAL  ACTION  OF  THE   HEART.  }fa 

and  at  the  same  time  occurs  the  beat  of  the  apex  against  the 
chest-wall.  During  this  time  the  carotid  pulse  may  be  felt. 

The  long,  first  sound,  as  indicated  in  the  diagram,  is  followed 
by  a  short  period  of  silence,  known  as  the  first  silence,  during 
which  the  radial  pulse  may  usually  be  felt. 

Immediately  following  the  first  silence  the  ventricular  dias- 
tole begins,  and  with  it  occurs  the  second  sound  of  the  heart, 
which,  as  indicated  in  the  diagram,  is  shorter  than  the  first. 
Following  the  second  sound  we  notice  the  second  or  long 
silence,  extending  through  the  period  of  rest  and  the  time  oc- 
cupied by  the  auricular  systole. 

In  some  cases  only  one  sound  of  the  heart  can  be  heard,  either 
at  the  apex  or  at  the  base.  In  such  instances,  in  order  to  deter- 
mine which  is  the  first  and  which  the  second,  it  is  absolutely 
necessary  to  associate  the  sound  with  the  arterial  pulsation.  This 
can  only  be  done,  in  the  majority  of  cases,  by  feeling  for  the 
carotid  pulse,  which  occurs  with  the  first  sound  of  the  heart. 
If  the  heart  were  beating  slowly,  it  might  be  easy  to  recog- 
nize the  position  of  the  radial  pulse  between  the  first  and  second 
sounds ;  but  as  the  length  of  the  first  silence,  during  which 
this  may  be  felt,  does  not  usually  exceed  the  tenth  of  a 
second,  it  is  difficult  to  be  certain  whether  it  accompanies 
the  latter  part  of  the  first  or  the  first  part  of  the  second  sound. 
Knowledge  of  the  instant  when  the  carotid  pulsation  takes 
place  is  indispensable  in  ascertaining  whether  an  abnormal 
sound  precedes  or  accompanies  the  systole  of  the  ventricles. 

The  regular  contraction,  dilatation,  and  rest  of  the  heart 
constitute  what  is  known  as  its  rhythm.  In  health  the  cardiac 
pulsations  follow  each  other  in  regular  succession,  about 
seventy  or  eighty  times  per  minute,  and  each  pulsation  is  simi- 
lar in  every  respect  to  those  which  precede  or  follow  it.  In 
disease  of  the  heart,  alterations  in  the  rhythm  are  among  the 
most  constant  signs ;  and  in  all  the  affections  giving  rise  to 
abnormal  sounds  produced  at  the  valvular  orifices,  the  signs 
occur  with  either  the  contraction  or  dilatation  of  the  organ. 
It  therefore  becomes  necessary  in  the  physical  diagnosis  of 
cardiac  disease  to  ascertain  the  rhythm  of  the  heart.  When  the 

*  / 

pulsations  are  of  normal  frequency  this  is  an  easy  matter,  il  we 
recollect  that  the  first  sound  is  dull,  heavy,  and  prolonged, 
while  the  second  sound  is  comparatively  short  and  clacking ; 


170 


THE   HEART   AND   AORTA. 


and  that  the  period  of  rest,  or  long  silence,  follows  the  second 
and  precedes  the  first  sound  ;  also  that  the  first  sound  is  coinci- 
dent with  the  carotid  pulse,  and  the  impulse  of  the  apex-beat 
against  the  chest- wall.  But  if  the  heart  is  beating  rapidly,  e.  g., 
more  than  a  hundred  times  per  minute,  it  is  always  difficult, 
and  frequently  it  is  impossible,  by  auscultation  alone  to  dis- 
tinguish between  the  two  sounds. 

If  we  divide  the  entire  period  of  the  cardiac  pulsations  into 
two  parts,  one  of  motion  and  the  other  of  rest,  it  at  once 
becomes  evident  that  the  more  rapid  the 
pulsations  the  shorter  must  be  the  period 
of  repose,  and  consequently  the  shorter 
will  be  the  silence  between  the  two  sounds 
of  the  heart.  This  is  well  illustrated  by  a 
series  of  circles  of  increasing  size  (Fig.  25). 
In  the  first  or  smallest  circle,  which  indi- 
cates the  most  rapid  pulsation  of  the  heart, 
the  intervals  between  the  first  and  second, 
and  the  second  and  first  sounds  are  equal ; 
whereas  in  the  largest  circle,  in  which  the 
interval  between  the  first  and  second  sound 
is  represented  by  the  same  distance  upon 
the  circumference  as  in  the  smaller  circle, 
the  time  between  the  second  and  the  first 
sound  is  greatly  increased,  as  indicated  by 
the  greater  distance  on  the  circumference. 
In  the  smaller  circle  the  time  between  the 
first  and  the  second  sounds  is  equal  to  that 
between  the  second  and  the  first,  while  in 
the  larger  the  time  between  the  first  and 
the  second,  which  corresponds  to  the 
period  of  motion,  is  only  about  one  fourth  as  great  as  that 
which  includes  the  period  of  rest  between  the  second  and  the 
first. 


FIG.  25. — (Loomis.) 


LECTURE  XVI. 
PHYSICAL  EXAMINATION   OF  THE   HEART. 

METHODS  OF  CARDIAC  EXPLORATION. 

The  methods  employed  in  examination  of  the  heart  are  five 
in  number,  namely,  inspection,  palpation,  mensuration,  percussion, 
and  auscultation. 

INSPECTION. — Upon  inspecting  a  patient  suffering  from  car- 
diac disease,  we  will  nearly  always  observe  a  peculiar  sodden 
expression,  with  puffiness  of  the  lower  eyelids.  In  many 
instances  there  is  marked  pulsation  of  the  veins  and  arteries  at 
the  base  of  the  neck  ;  but  slight  pulsation  of  the  jugular  vein 
is  not  a  sign  of  cardiac  disease.  Presystolic,  jugular  pulsation, 
when  slight,  may  be  caused  normally  by  the  auricular  contrac- 
tion ;  but  distinct  systolic  pulsation  in  this  position  is  always 
associated  with  more  or  less  dilatation  of  the  right  side  of  the 
heart,  which  may  result  from  protracted  emphysema,  mitral 
disease,  or  obstruction  of  the  pulmonary  artery  by  embolism  or 
thrombosis.  Marked  systolic  pulsation  in  the  jugular  veins, 
especially  on  the  right  side  of  the  neck,  is  always  associated 
with  dilatation  of  the  right  ventricle,  and  regurgitation  of  blood 
through  the  tricuspid  valves,  by  which  the  impulse  is  trans- 
mitted directly  to  the  jugular  veins,  as  there  are  no  valves 
guarding  the  opening  of  the  descending  vena  cava  into  the 
right  auricle.  Pulsation  in  the  veins  is  always  most  distinct 
when  the  patient  is  lying  down,  and  it  may  be  rendered  still 
more  noticeable  by  pressing  the  blood  upward  in  the  vein  with 
the  finger,  and  allowing  the  vessel  to  refill  from  below. 

Visible  pulsation  in  the  superficial  arteries  is  not  uncommon  in 
conditions  of  health  ;  but  when  this  is  excessive  and  symmetrical 
in  the  carotid,  subclavian,  and  brachial  arteries,  it  is  always  due 
to  hypertrophy  and  dilatation  of  the  left  ventricle,  with  regurgi- 
tation through  the  aortic  valves.  Marked  pulsation  confined  to 
one  subclavian  or  carotid  artery  usually  indicates  dilatation  of 
the  vessel,  and  the  commencement  of  an  aneurism. 


,72  THE   HEART   AND  AORTA. 

By  inspecting  the  chest,  we  obtain  information  regarding  the 
form  of  the  cardiac  region  and  the  position  and  character  of 
the  apex-beat. 

Form  of  the  Prcecordia. — Enlargement  or  bulging  of  the  prae- 
cordial  region  may  be  normal,  but  it  is  frequently  due  to 
enlargement  of  the  heart,  or  effusion  into  the  pericardial  sac. 
In  this  latter  instance,  the  intercostal  spaces  are  more  prominent 
than  in  the  former.  The  unusually  distinct  pulsations,  which 
are  often  seen  in  children  and  emaciated  persons,  have  been 
mistaken  for  bulging ;  but  such  errors  may  be  easily  avoided 
by  care  in  inspection,  and  by  palpation. 

Rachitis  may  cause  bulging  of  the  praecordial  region,  but  in 
such  instances  a  corresponding  depression  is  usually  found  on 
the  posterior  aspect  of  the  chest,  immediately  to  the  left  of  the 
spine,  and  the  spine  itself  is  generally  curved. 

Prominences  caused  by  aneurisms  of  the  aorta  are  found 
only  above  the  fourth  rib. 

Depression  in  the  prascordial  region,  of  a  permanent  character, 
usually  indicates  previous  pericarditis  with  adhesion  of  the 
two  surfaces  of  the  pericardium  to  each  other,  and  of  the  peri- 
cardium to  the  costal  pleura.  Care  must  be  taken  not  to  con- 
found with  this  condition  those  rhythmical  depressions  which 
may  occur  independent  of  adhesions,  as  the  result  of  atmos- 
pheric pressure.  These  take  place  when  the  heart  is  enlarged, 
and  the  left  lung  contracted,  provided  the  person  has  thin  and 
elastic  chest-walls. 

Apex-Beat. — Alterations  in  the  position,  character,  and  force 
of  the  apex-beat  may  also  be  detected  by  inspection.  The 
apex  is  crowded  upward  and  outward  by  hypertrophy  of  the 
left  lobe  of  the  liver  or  by  abdominal  tumors.  It  may  be 
carried  directly  upward  to  a  point  above  the  fifth  rib  by  peri- 
cardial effusions  ;  and  it  is  raised  by  contraction  of  the  left  lung, 
as  in  fibroid  phthisis.  It  is  crowded  downward  and  to  the 
right,  when  the  left  lung  is  enlarged  by  emphysema ;  or  it  may 
be  drawn  in  the  same  direction  by  contraction  of  the  right 
lung.  It  is  crowded  to  the  right  by  collections  of  fluid  or  of 
air  in  the  left  pleural  sac,  or  by  large  tumors  occupying  that 
side  of  the  chest ;  and  to  the  left,  by  corresponding  conditions 
upon  the  right  side.  It  is  carried  downward  by  aneurisms  or 
by  other  mediastinal  tumors ;  and  downward  and  somewhat 


METHODS   OF   CARDIAL   EXPLORATION. 

inward  by  hypertrophy  of  the  right  ventricle.  It  is  carried 
downward  and  to  the  left  by  hypertrophy  of  both  ventricles ; 
but  in  uncomplicated  hypertrophy  the  apex  seldom  extends 
more  than  an  inch  to  the  left  of  its  normal  position.  It  is  also 
carried  downward,  and  often  far  to  the  left,  by  enlargement  of 
the  heart,  whether  the  result  of  dilatation  or  of  dilatation  and 
hypertrophy  combined.  The  significance  of  alterations  in  the 
position  of  the  apex-beat  is  shown  at  a  glance  in  the  following 
table  : 

Displacements  of  the  Apex. 

Apex  raised.  Pericardial  effusions. — Contraction  of  left 

lung. 

Apex  more  or  less  upward  and  outward        Hypertrophy  of  the  left  lobe  of  the  liver, 
(to  the  left).  —Abdominal  tumors. 

Apex  depressed.  Aneurisms  or  other  mediastinal  tumors. 

Apex  more  or  less  downward  and  to  the        Pulmonary  emphysema.— Contraction  of 
right-  the  right  lung,   or  hypertrophy  of  the 

right  ventricle. 

Apex  more  or  less  downward  and  to  the        Hypertrophy  of  the  left  or  both  ventricles, 
left.  —Dilatation  of  the  heart.— Hypertro- 

phy with  dilatation. 

Apex  crowded  to  the  right  or  left.  Fluid,  air,  or  tumors  in  opposite  side  of 

chest. 

Area  of  Cardiac  Impulse. — The  area  over  which  the  impulse 
can  be  seen  is  increased  in  all  those  diseases  which  cause  en- 
largement of  the  heart. 

Feeble  pulsations  above  the  fourth  rib  are  usually  due  to 
auricular  contraction,  but  they  may  be  caused  by  an  aneurism 
of  the  aorta.  These  two  conditions  can  be  distinguished  from 
each  other  by  noting  the  time  of  their  occurrence.  Pulsation 
of  the  auricles  always  precedes  the  apex-beat,  while  that  of  an 
aneurism  must  necessarily  follow  or  accompany  it.  If  the 
heart  is  acting  slowly,  this  distinction  can  be  made  easily  by 
ordinary  inspection,  but  this  is  not  the  case  if  it  is  beating  rapidly. 
Under  such  circumstances  the  differentiation  is  facilitated  by 
attaching  by  means  of  wax,  two  bristles  each  carrying  a  paper 
flag,  to  the  two  pulsating  points,  one  over  the  apex  and  the 
other  above  the  fourth  rib.  By  watching  the  movements  of 
the  little  flags  it  will  be  easy  to  determine  which  is  first  and 
which  second. 


T<7/1  THE   HEART  AND  AORTA. 

1/4 

Character  and  Force  of  Impulse.— In  dilatation  of  the  ventricles, 
and  when  agglutination  of  the  two  surfaces  of  the  pericardium 
has  taken  place,  the  character  of  the  impulse  is  wavy  or  undu- 
lating ;  and  it  may  sometimes  be  seen  over  the  entire  prsecor- 
dial  region. 

Alterations  in  the  force  of  the  impulse  may  ordinarily  be 
recognized  upon  inspection,  but  can  be  better  appreciated  by 
palpation. 

PALPATION. — Before  examining  the  chest  by  palpation  it  is 
always  desirable  to  ascertain  the  condition  of  the  pulse,  the 
signs  furnished  by  which  are  frequently  sufficient  to  establish 
the  diagnosis. 

Pulse. — If  the  radial  pulse  is  of  unequal  force  upon  the  two 
sides  it  is  probably  caused  by  an  aneurism,  though  it  may 
depend  upon  an  abnormal  distribution  of  the  arteries.  In  the 
latter  case  pulsations  in  the  brachial  arteries  would  be  found 
alike  on  the  two  sides;  whereas,  in  case  of  aortic  aneurism,  they 
would  vary  in  force. 

If  the  pulse  is  small  and  weak,  when  the  arm  is  hanging  in 
the  natural  position,  and  if  it  disappears  upon  raising  the  arm, 
anaemia  is  present,  and  it  may  be  the  only  cause  for  this  sign. 
When  the  arm  is  in  the  natural  position,  if  the  pulse  is  small 
and  weak,  and  if  it  maintains  the  same  characteristics  when 
the  arm  is  elevated,  there  is  likely  to  be  disease  at  the  mitral 
valves ;  if  the  pulse  is  also  very  irregular,  it  is  probably  caused 
by  mitral  stenosis. 

If  the  pulse  is  small  and  irregular,  but  distinct,  and  upon 
elevation  of  the  arm  becomes  still  more  distinct,  two  lesions 
are  present,  one  at  the  mitral  valves,  and  the  other  at  the 
aortic. 

If  the  pulse  is  full  and  distinct,  with  the  arm  in  its  natural 
position,  and  becomes  much  more  distinct,  and  assumes  the 
characteristics  known  as  "  hammer "  pulse,  when  the  arm  is 
elevated  there  is  regurgitation  through  the  aortic  valves,  with 
more  or  less  hypertrophy  and  dilatation  of  the  left  ventricle. 

The  conditions  of  the  pulse,  as  shown  by  the  sphygmograph, 
though  very  interesting,  cannot  as  yet  be  considered  of  much 
importance  clinically.  The  tracings  will  be  illustrated  in  an- 
other lesson. 

Upon  examining  the  chest  by  palpation,  we  obtain  evidence 


METHODS   OF   CARDIAC   EXPLORATION.  !75 

concerning  the  force,  frequency,  and  regularity  of  the  heart's 
action,  and  we  may  detect  abnormal  pulsations  or  thrills. 

By  pressing  firmly  upon  the  sternum  with  one  hand,  while 
the  other  is  pressed  upon  the  back,  we  are  sometimes  able  to 
detect  pulsations,  in  a  slightly  dilated  aorta,  which  could  not 
be  found  in  the  ordinary  manner. 

Position  of  impulse. — Forcible  pulsation  above  the  fourth  rib 
may  be  due  to  an  aneurism ;  but  if  observed  to  the  left  of  the 
sternum,  it  is  ordinarily  caused  by  hypertrophy  and  dilatation 
of  the  left  auricle.  The  two  conditions  may  be  differentiated 
by  observing  whether  the  pulsation  precedes  or  follows  the 
apex-beat. 

When  the  left  lung  is  retracted  from  the  base  of  the  heart, 
pulsation  of  the  pulmonary  artery  may  be  frequently  seen  in 
the  second  intercostal  space.  It  can  be  distinguished  from 
pulsations  of  the  auricle  by  the  time  of  its  occurrence. 

Abnormal  pulsations  along  the  course  of  the  aorta  are 
nearly  always  aneurismal ;  but  in  very  rare  instances  they  are 
caused  by  displacement  of  the  artery,  as  in  rachitis.  If  the 
pulsations  are  feeble,  they  can  be  most  distinctly  felt  during 
expiration. 

Pulsation  beneath  the  lower  portion  of  the  sternum,  and  in 
the  epigastric  region,  with  disappearance  of  the  apex-beat,  is  a 
sign  of  enlargement  of  the  right  ventricle. 

Force  increased. — The  force  of  the  heart  may  be  increased  or 
diminished. 

It  is  increased  in  simple  hypertrophy,  and  in  hypertrophy 
with  dilatation,  whenever  the  former  more  than  compensates 
for  the  latter.  It  is  slightly  increased  in  the  early  stages  of 
endocarditis,  and  of  pericarditis ;  and  it  is  increased  by  simple 
irritability  of  the  heart,  as  in  palpitation  due  to  hysteria. 

Occasionally  a  double  shock  is  felt  in  case  of  extensive 
hypertrophy  and  dilatation,  due  to  the  rebound  of  the  heart 
after  its  systole. 

The  force  is  diminished:  whenever  the  chest-walls  are  very 
thick,  in  consequence  of  a  large  amount  of  adipose  tissue  ;  when 
the  heart  is  abnormally  separated  from  the  chest-walls,  as  m 
pulmonary  emphysema ;  and  when  there  is  effusion  into  the 
pericardial  sac.  It  is  also  diminished  when  the  heart  is  feeble 
from  any  cause,  whether  it  be  atrophy,  fatty  degeneration  and 


j-5  THE   HEART   AND   AORTA. 

softening,  or  general  muscular  debility  resulting  from  pro- 
tracted or  low  forms  of  fever,  or  other  disease. 

The  position  of  the  apex-beat  can  often  be  detected  by 
palpation,  when  it  is  not  perceptible  upon  inspection.  It  is 
altered  by  the  diseases  which  I  mentioned,  in  speaking  of 
inspection. 

Frequency. — The  frequency  of  the  heart's  action  is  increased 
in  such  a  great  variety  of  diseases  that  it  is  not  a  sign  of  much 
importance  in  the  diagnosis  of  cardiac  affections. 

Irregularity  of  the  heart's  action  is  ordinarily  a  sign  of  disease 
in  this  organ. 

Friction  f remit  us. — When  the  pericardial  surfaces  are  rough- 
ened by  exudation,  friction  fremitus  may  be  obtained.  This  is 
usually  most  distinct  in  the  fourth  intercostal  space,  near  the 
left  margin  of  the  sternum. 

Purring  tremor. — Regurgitation  through  the  valvular  orifices 
gives  rise  to  a  peculiar  vibration  known  as  the  purring  tremor 
or  thrill,  which  may  be  felt  by  the  fingers.  This  is  sometimes 
detected  by  simply  touching  the  surface,  but  in  other  instances 
firm  pressure  must  be  made. 

Exceptional. — The  same  sensation  is  occasionally  communicated  from  the  larger 
arteries. 

Epigastric  pulsation. — Feeble  epigastric  pulsation  is  frequently 
found  in  perfectly  healthy  individuals ;  but  pulsation  in  this 
locality,  associated  with  absence  of  the  apex-beat  from  its  nor- 
mal position,  is  generally  the  result  of  dilatation  of  the  right  ven- 
tricle, with  or  without  hypertrophy.  This  is  a  common  sign  of 
dilatation  of  the  right  side  of  the  heart  caused  by  pulmonary 
emphysema.  Epigastric  pulsation  may  be  due  to  the  impulse 
of  the  abdominal  aorta,  especially  in  emaciated  people  who 
have  formerly  been  of  full  habit.  It  occurs  also  when  a  tumor 
rests  upon  the  aorta  in  such  a  manner  as  to  be  lifted  with 
each  pulsation  ;  and  it  is  one  of  the  signs  of  aneurism  of  this 
artery. 

Exceptional. — Sometimes  epigastric  pulsation  is  due  to  the  action  of  the  heart  upon 
the  left  lobe  of  the  liver. 

Hepatic  pulsation  in  a  few  rare  instances  is  caused  by  venous  regurgitation  from  a 
dilated  right  ventricle,  through  the  tricuspid  valves  and  the  right  auricle,  into  the 
ascending  vena  cava.  It  sometimes  extends  over  the  entire  hypochondriac  region  of 
the  right  side,  but  in  other  instances  it  is  limited  to  a  portion  of  the  liver. 


METHODS   OF   CARDIAC   EXPLORATION.  I77 

Similar  pulsations  are  observed  in  very  rare  cases,  as  the  result  of  an  aneurism,  the 
pulsations  of  which  are  transmitted  through  the  liver. 

Sometimes  a  peculiar  pulsation  is  communicated  to  the  epigastric  region  by  the 
systole  of  the  heart,  the  apex  of  which  draws  the  diaphragm  upward  in  contraction, 
instead  of  crowding  it  downward,  in  consequence  of  agglutination  of  the  two  surfaces 
of  the  pericardium.  This  pulsation  is  the  reverse  of  that  ordinarily  observed,  the 
expansion  taking  place  with  the  dilatation  instead  of  with  the  contraction  of  the  heart. 

PERCUSSION. — By  percussion,  we  learn  the  size  of  the  heart, 
or  detect  collections  of  fluid  or  air  in  the  pericardium.  It  is 
generally  considered  very  difficult  to  map  out  this  organ  by 
percussion,  but  if  attention  is  paid  to  the  following  rules,  you 
will  find  it  comparatively  easy.  In  the  first  place  the  patient 
should  be  in  the  recumbent  posture,  when  the  examination  is 
made,  and  the  force  of  the  blow  should  be  proportionate  to  the 
depth  of  the  part  to  be  examined.  If  we  wish  to  learn  the 
extent  of  the  area  where  the  heart  is  not  covered  by  lung,  we 
must  percuss  lightly  ;  and  if  we  wish  to  learn  the  deeper  out- 
lines of  the  organ,  a  harder  stroke  must  be  made. 

For  clinical  purposes,  it  is  not  necessary  to  find  the  exact 
limits  of  the  heart  in  every  direction,  for  our  results  will  be 
equally  good  if  we  ascertain  simply  the  upper,  lower,  and 
lateral  lines  of  dulness,  over  its  greater  diameters. 

To  find  the  base  of  the  heart,  percussion  should  be  performed 
on  a  line  about  an  inch  to  the  left  of  the  sternum,  so  as  to  avoid 
the  dulness  occasioned  by  the  aorta  and  the  pulmonary  artery, 
which  in  no  way  differs  from  that  of  the  heart  itself.  On  this 
line  percussion  should  be  made  from  above  downwards,  until 
we  reach  the  upper  limit  of  cardiac  dulness;  which  will  ordi- 
narily be  found  at  the  third  rib. 

To  locate  the  lateral  boundaries,  percussion  should  be  made 
in  the  fourth  intercostal  spaces.  Beginning  in  the  right  mam- 
mary region,  where  there  is  perfect  resonance,  the  examination 
should  be  carried  gradually  toward  the  sternum,  until  the  car- 
diac dulness  is  reached ;  which  will  usually  be  about  half  an 
inch  to  the  right  of  this  bone. 

Upon  the  left  side,  the  examination  should  be  commenced  near 
the  left  of  the  nipple,  and  carried  gradually  toward  the  sternum, 
until  cardiac  dulness  is  obtained;  which  is  usually  about  half 
an  inch  to  the  right  of  the  mammillary  line. 

It  is  a  difficult  matter,  by  simple  percussion,  to  find  the  lower 
border  of  the  heart,  for  the  reason  that  it  lies  immediately 

12 


!78  THE    HEART   AND   AORTA. 

above  the  left  lobe  of  the  liver,  and  a  distinction  between  the 
dull,  or  flat,  sounds  produced  by  these  two  organs  is  hardly 
practicable.  If  you  will  find  the  apex  of  the  heart  either  by 
palpation  or  by  auscultation,  and  then  the  upper  surface  of  the 
liver,  in  the  right  mammary  region,  by  forcible  percussion,  you 
may  draw  a  straight  line  between  these  two  points  and  it  will 
correspond  almost  exactly  with  the  inferior  border  of  the 
heart. 


LECTURE     XVII. 
PHYSICAL   EXAMINATION   OF   THE   HEART,  ETC. 

Superficial  cardiac  dulness. — In  a  small  triangular  space  at 
the  inner  side  of  the  left  mammary  region,  and  at  the  lower 
part  of  the  sternum,  the  heart  lies  close  to  the  chest-wall,  not 
being  covered  by  the  anterior  border  of  the  lungs  (Fig.  i,  page 
3).  This  area,  which  is  about  two  and  one  half  inches  in  width, 
and  nearly  the  same  in  altitude,  is  known  as  the  area  of  super 
ficial  cardiac  dulness.  It  might  appropriately  be  called  the 
area  of  cardiac  flatness.  The  apex  of  this  triangle  is  at  the 
centre  of  the  sternum,  nearly  on  a  line  with  the  fourth  rib;  the 
base  corresponds  to  the  costal  cartilage  of  the  sixth  rib. 

This  space  is  altered  in  extent  by  various  diseases  of  the 
heart  and  the  lungs.  Its  area  is  usually  increased  by  all  those 
affections  which  cause  enlargement  of  the  heart,  as  hypertrophy 
and  dilatation,  or  simple  hypertrophy. 

In  some  cases  of  hypertrophy,  an  emphysematous  condition  of  the  lung  more  than 
counterbalances  the  enlargement  of  the  heart,  and  thus  the  space,  instead  of  being 
increased,  will  be  diminished. 

This  area  is  also  increased  by  effusions  of  fluid  into  the  peri- 
cardial  sac. 

In  the  normal  condition,  the  area  is  increased  by  forced 
expiration,  and  it  is  diminished  by  deep  inspiration. 

The  area  of  superficial  cardiac  dulness  is  diminished:  by  em- 
physema, which  crowds  the  anterior  border  of  the  left  lung 
over  the  heart ;  by  pneumothorax ;  and  it  is  obliterated  in 
the  rare  disease  known  as  pneumopericardium,  in  which  air 
or  gas  collects  in  the  pericardial  sac,  and  the  normal  dulness  is 
supplanted  by  tympanitic  resonance. 

Deep  cardiac  dulness—  The  area  of  deep-seated  cardiac  dul- 
ness corresponds  to  the  borders  of  the  heart.  It  extends 
usually  from  the  third  rib  above,  to  the  resonance  of  the 
stomach,  below;  and  laterally  fio.n  about  three  fourths  of  an 


1 80 


THE   HEART   AND   AORTA. 


inch  to  the  right  of  the  sternum,  to  within  half  an  inch  of  the 
left  nipple.  This  area  of  dullness  is  increased  in  those  affections 
which  cause  enlargement  of  the  heart,  as  hypertrophy  and 
dilatation  ;  and  by  pericardial  effusions. 

When  the  dulness  is  first  increased  in  the  upper  portion  of 
the  praecordial  space  above  the  third  ribs,  you  may  be  almost 
certain  that  there  is  pericardial  effusion,  for  an  increase  in  the 
vertical  diameter  of  this  area  is  seldom  found  in  disease  of  the 
heart  itself. 

In  the  beginning  of  pericardial  effusions,  the  fluid  collects 


(Rvrii 

/\\\  \x     X    ~  M 


/I 

-M 


^  *  m/  // 
H^Hf   //:/ 

B-''  / °<i  i 
Sana   / /  I 


FIG.   26. — Pericarditis. 

about  the  arteries  at  the  base  of  the  heart,  where  it  causes  dul- 
ness. Very  soon,  the  weight  of  the  fluid  overcomes  the  tension 
of  the  pericardium  and  surrounding  lungs,  and  dulness  occurs 
in  the  lower  portion  of  the  prascordial  space,  causing  an  increase 
in  the  lateral  diameter  of  the  deep-seated  area  of  dulness. 

As  soon  as  any  considerable  amount  of  effusion  has  taken 
place,  you  can  recognize  a  dull  space  more  or  less  triangular  in 
shape,  like  the  pericardial  sac,  with  the  apex  upward  and  the 
base  downward  (Fig.  26). 

Where  the  effusion  is  very  great,  this  dulness  may  extend 


PHYSICAL   EXAMINATION.  !gi 

laterally  from  near  the  right  nipple  to  a  point  an  inch  or  more 
to  the  left  of  the  left  nipple.  In  this  condition  the  dulness  will 
be  found  extending  considerably  to  the  left  of  the  apex  of  the 
heart,  which  may  be  located  by  auscultation.  This  fact  will 
enable  us  to  distinguish  between  effusions  into  the  pericardium 
and  enlargement  of  the  heart.  The  area  of  dulness  in  peri- 
cardial  effusions  is  greater  when  the  patient  is  sitting  or  stand- 
ing, than  when  lying  upon  the  back.  In  the  lattsr  position, 
the  fluid  gravitates  toward  the  posterior  part  of  the  pericardium, 
and  the  anterior  border  of  the  lung  insinuates  itself  further 
between  the  pericardium  and  the  thoracic  walls. 

The  area  of  cardiac  dulness  is  apparently  increased  by  con- 
solidation of  the  left  lung. 

The  outlines  of  the  heart  may  be  traced  a  little  more  easily  by  auscultatory  percus- 
sion than  by  the  ordinary  method  of  percussing.  In  practicing  this  method,  you  may 
employ  either  the  solid  stethoscope  made  for  this  purpose,  or  the  ordinary  binaural 
stethoscope  with  the  small  chest-piece.  Whichever  you  use,  the  chest  pkce  should  be 
placed  over  the  most  superficial  part  of  the  heart,  and  percussion  should  be  made  from 
the  resonant  portion  of  the  lungs  toward  the  central  portion  of  the  organ  ;  from  above 
downward,  and  laterally  from  without  inward.  By  this  method,  as  soon  as  the  outer- 
most limits  of  the  pericardium  are  reached,  the  change  in  the  percussion  note  is  at  once 
perceptible  to  the  listener. 

CARDIAC  AUSCULTATION. — In  auscultation  over  the  heart, 
accurate  information  cannot  usually  be  obtained  by  the  unaided 
ear ;  but  by  mediate  auscultation,  especially  if  the  small  chest- 
piece  of  the  stethoscope  be  used,  most  satisfactory  results  can 
be  secured. 

For  cardiac  auscultation,  the  patient  should  be  in  the  recum- 
bent position  during  at  least  a  portion  of  the  examination. 

The  examination  should  be  commenced  while  the  individual 
is  breathing  naturally.  Subsequently,  the  patient  should  be 
directed  to  take  three  or  four  deep  inspirations,  which  will 
enable  us  more  clearly  to  detect  sounds  that  are  produced  by 
the  lungs.  Then  he  should  hold  his  breath  for  a  few  seconds, 
which  will  enable  us  to  eliminate  pulmonary  sounds,  and  will 
render  the  heart-signs  more  distinct. 

The  examination  must  not  stop  with  the  praecordial  space, 
but  should  be  carried  over  the  entire  chest,  and  the  various 
points  must  be  localized  at  which  the  heart-sounds,  both  normal 
and  abnormal,  may  be  heard  most  distinctly. 


l82  THE  HEART  AND  AORTA. 

It  is  not  the  point  at  which  the  sound  may  be  heard  which 
is  of  diagnostic  importance,  but  the  point  at  which  it  is  loudest. 

CAUSE  OF  HEART-SOUNDS. — Considerable  difference  of 
opinion  exists  regarding  the  cause  of  the  heart-sounds.  All 
concede  that  the  second  sound  is  usually  produced  by  clos- 
ure of  the  semilunar  valves;  and  it  is  generally  admitted 
that  several  elements  enter  into  the  production  of  the  first 
sound,  though  the  importance  of  each  of  these  is  variously 
estimated  by  different  authors. 

The  main  factors  in  the  production  of  the  first  sound  are : 
first,  the  closure  of  the  mitral  and  of  the  tricuspid  valves ; 
second,  the  contraction  of  the  muscular  fibres  of  the  heart ; 
third,  the  impulse  of  the  apex  against  the  chest-walls.  Besides 
these  elements,  friction  of  the  blood  against  the  inner  surface 
of  the  heart,  and  of  the  heart  against  the  surrounding  tissues, 
doubtless  plays  some  part  in  forming  this  sound.  I  believe 
that  the  part  taken  in  the  production  of  the  first  sound  by  the 
contractio'n  of  the  muscular  fibres  is  much  greater  than  is 
generally  supposed,  as  may  be  shown  by  the  following  simple 
experiment.  Place  the  end  of  your  stethoscope  over  the  body 
of  a  muscle  which  can  be  contracted  or  relaxed  without  moving 
the  integuments,  as,  for  example,  upon  the  ball  of  the  thumb ; 
now  flex  and  extend  the  terminal  phalanx  regularly  about 
seventy  times  a  minute  and  you  will  hear,  what  almost  seems, 
the  heart  beating  immediately  beneath  your  instrument.  Skoda 
states  that  the  heart-sounds  may  be  produced  by  the  arteries.  "  It 
appears  to  follow  with  tolerable  certainty  that  both  ventricles, 
the  pulmonary  artery  and  aorta  are  capable,  each  separately, 
of  producing  both  the  first  and  second  sound  perceptible  in  the 
region  of  the  heart." 

In  health,  the  first  sound  of  the  heart  is  dull,  soft,  and  pro- 
longed, compared  with  the  second,  and  it  is  synchronous  with 
the  systole  of  the  heart,  and  therefore  with  the  apex-beat  and 
carotid  pulse.  Its  point  of  maximum  intensity  corresponds  to 
the  apex-beat. 

The  second  sound,  which  is  dependent  upon  closure  of  the 
semilunar  valves  caused  by  resilience  of  the  arteries,  is  shorter, 
sharper,  and  more  superficial  than  the  first  sound,  and  possesses 
none  of  that  muscular  element  which  we  observe  in  the  latter. 
It  coincides  with  the  diastole  of  the  heart  and  follows  the 


PHYSICAL   EXAMINATION.  jg, 

arterial  pulse  and  apex-beat.  It  is  heard  with  the  greatest 
intensity  at  the  articulation  of  the  third  left  costal  cartilage 
with  the  sternum.  Immediately  following  the  second  sound  is 
the  period  of  silence,  which  varies  in  duration  with  the  rapidity 
of  the  heart's  action. 

The  intensity  of  the  heart's  sounds  varies  in  different  indi- 
viduals with  the  changing  force  of  the  impulse  and  the  conforma- 
tion of  the  chest-walls,  and  with  peculiar  idiosyncrasies,  which 
we  cannot  well  understand.  As  a  rule,  the  heart-sounds  are 
louder  in  children  and  in  those  with  thin  chest-walls  than  in 
adults  or  in  those  with  the  parietes  very  muscular  or  thickened 
by  adipose  tissue. 

The  extent  of  the  area  over  which  the  cardiac  sounds  may 
be  heard  will  vary  with  the  adaptability  of  the  surrounding 
organs  for  transmitting  sounds.  If  the  lungs  are  solidified  the 
sounds  may  be  heard  much  farther  than  in  the  normal  condi- 
tion ;  but  if  the  lungs  are  emphysematous  the  sounds  are  not 
heard  as  far  as  in  health. 

Usually  the  sounds  produced  upon  the  right  side  are  heard 
loudest  over  the  corresponding  portion  of  the  heart,  and  to- 
ward the  right  side  of  the  sternum  ;  while  those  produced  upon 
the  left  are  heard  loudest  over  the  left  side  of  the  heart  and 
nearer  the  left  nipple. 

Since  the  normal  heart-sounds  vary  considerably  in  different 
individuals,  you  will  recognize  the  necessity  for  studying  a 
large  number  of  healthy  hearts,  for  no  one  individual  can  be 
taken  as  a  standard. 

MODIFICATIONS   OF  THE   HEART-SOUNDS  BY  DISEASE. 

The  heart-sounds  are  modified  by  disease  in  their  intensity, 
pitch,  quality,  seat,  and  rhythm.  They  may  be  preceded,  accom- 
panied, or  followed  by  abnormal  sounds  known  as  murmurs  ; 
or  murmurs  may  entirely  supplant  the  natural  sounds. 

INTENSITY  INCREASED.— The  intensity  of  the  heart-sounds 
is  increased. by  hypertrophy  of  the  ventricles,  by  nervous 
irritability,  by  palpitation  of  the  heart,  by  consolidation 
of  adjacent  lung  tissue,  and  exceptionally,  by  dilatation  of  the 
heart. 

INTENSITY  DIMINISHED.— The  intensity  of  these  sounds  is 
diminished  by  simple  dilatation  of  the  ventricles,  by  fatty  de- 


!34  THE    HEART   AND   AORTA. 

generation  of  the  muscular  fibres  of  the  heart,  or  by  deposition 
of  fat  between  them,  or  on  the  surface  of  the  organ  ;  by  soften- 
ing or  debility  of  the  muscular  fibres  as  the  result  of  protracted 
disease — for  example,  typhus  or  typhoid  fever;  and  by  peri- 
cardial  effusions.  It  is  also  diminished  by  emphysema  of  the 
lungs.  The  heart-sounds  are  sometimes  masked  by  bronchial 
rales. 

QUALITY  MODIFIED. — The  quality  of  the  heart-sounds  is 
considerably  altered  in  a  great  variety  of  diseases.  The  sounds, 
instead  of  being  clear  and  distinct,  as  in  typical  healthy  cases, 
may  be  slightly  muffled,  or  they  may  be  associated  with  an  in- 
distinct and  transient  sound  which  closely  resembles  a  murmur. 
This  impurity  of  the  heart-sounds,,  unless  associated  with  other 
signs  of  cardiac  disease,  is  of  no  diagnostic  importance,  because 
it  very  frequently  occurs  as  the  result  of  pulmonary  disease 
when  the  heart  is  in  no  way  involved,  and  it  is  often  noticed 
in  healthy  individuals. 

PITCH  AND  QUALITY. — The  first  sound  of  the  heart  is 
rendered  duller  and  lower  in  pitch  than  natural,  by  hypertrophy 
of  the  ventricles,  with  thickening  of  the  tricuspid  and  mitral 
valves.  The  second  sound  is  modified  in  the  same  way  by 
thickening  of  the  semilunar  valves  without  regurgitation,  and 
by  loss  of  elasticity  in  the  arterial  walls. 

The  first  sound  of  the  heart  is  sharper  and  higher  pitched 
than  normal  in  dilatation  of  the  ventricles  without  alteration 
of  the  auriculo-ventricular  valves. 

The  second  sound  of  the  heart  may  be  higher  pitched  than 
natural,  or  in  other  words,  accentuated,  at  either  the  aortic  or 
the  pulmonary  orifice. 

At  the  aortic  orifice,  this  sound  is  somewhat  intensified  by 
hypertrophy  of  the  left  ventricle,  due  to  obstruction  in  the 
artery.  A  ventricle  thus  hypertrophied  propels  the  blood 
with  increased  force  into  the  aorta,  unduly  distends  this  vessel, 
and  thus  causes  sudden  and  more  forcible  contraction  of  the 
artery,  and  consequently  a  sharper  sound  from  the  semilunar 
valves.  Well  marked  accentuation  of  the  second  sound  in  this 
position  results  from  setting  back,  on  the  valves,  of  an  increased 
volume  of  blood,  and  it  is  always  caused  by  dilatation  of  the 
aorta. 

Accentuation  of  the  second  sound  at  the  pulmonary  orifice 


PHYSICAL   EXAMINATION.  jgc 

occurs  in  a  great  variety  of  diseases.  It  is  the  most  persistent 
of  all  the  signs  of  cardiac  disease,  but  it  is  also  found  in  nearly 
every  case  of  pulmonary  congestion  from  whatever  cause. 
Whenever  there  is  obstruction  or  regurgitation  at  the  mitral 
orifice  there  must  be  increased  tension  of  the  blood  in  the  left 
auricle  and  in  the  pulmonary  veins,  which  will  be  transmitted 
through  the  short  pulmonary  circuit  back  to  the  pulmonary 
arteries.  This  will  cause  a  sudden  and  sharper  closure  of  the 
valves  which  guard  the  outlet  of  the  right  ventricle.  Obstruc- 
tion in  the  pulmonary  circuit  from  disease  of  the  lungs,  by 
inducing  hypertrophy  and  dilatation  of  the  right  ventricle, 
causes  extreme  distention  of  the  pulmonary  artery  with  each 
pulsation,  and  consequent  accentuation  of  the  second  sound  in 
the  pulmonary  area. 

The  heart-sounds  become  metallic  or  tinkling  in  quality  in 
irritable  conditions  of  the  heart  and  when  the  stomach  is  dis- 
tended with  gas. 

Exceptional. — The  heart-sounds  are  very  metallic  in  character  in  the  rare  disease 
known  as  pneumopericardium.  They  are  sometimes  metallic  in  left  pneumothorax. 
The  same  character  is  sometimes  noticed  with  the  second  sound,  at  the  aortic  orifice, 
when  there  is  atheroma  of  this  vessel  limited  to  its -initial  portion. 

SEAT. — The  seat  of  the  heart  sounds  may  be  altered  by 
several  diseases.  The  sounds  obtainable  over  the  apex  are 
heard  above  their  normal  position,  whenever  ^the  abdominal 
organs  are  so  enlarged  as  to  encroach  upon  the  thoracic  cavity  ; 
for  example,  in  distention  of  the  stomach,  or  enlargement  of  the 
liver,  and  also  in  ascites  or  in  cases  of  large  ovarian  tumors. 
They  are  also  heard  above  their  normal  position  when  effusion 
is  present  in  the  pericardial  sac. 

These  sounds  are  heard  below  their  usual  seat,  when  the 
apex  is  depressed  by  tumors  in  the  mediastinum,  or  by  hyper- 
trophy with  dilatation  of  the  auricles.  They  are  displaced 
laterally  by  pleuritic  effusions,  pneumothorax,  and  by  deform- 
ities of  the  chest.  They  are  displaced  to  the  left,  whenever 
the  heart  is  enlarged,  whether  by  hypertrophy  or  by  dilatation. 

RHYTHM.— The  rhythm  of  the  heart-sounds  is  altered  by  many 
diseases. 

Intermittent  rhythm.— Frequently  the  heart  acts  regularly  for 
some  time  and  then  drops  one  or  more  beats  to  go  on  again 
with  its  regular  pulsations.  This  is  known  as  an  intermittent 


THE    HEART   AND   AORTA. 

rhythm.  If  the  intermittent  rhythm  includes  the  period  of  one 
pulsation  only,  it  is  of  no  special  importance,  as  such  phenomena 
occur  under  a  variety  of  circumstances,  independent  of  cardiac 
disease. 

It  is  a  curious  fact  that  intermission  in  the  heart's  action  often  occurs  in  some  people 
just  preceding  a  thunder-storm. 

But  if  this  intermission  occupies  the  time  of  two  or  three 
pulsations,  and  if  the  heart's  action  is  irregular — that  is,  beating 
rapidly,  then  slowly,  finally  intermitting,  and  then  starting  up 
with  rapid  pulsations,  as  if  to  make  up  for  lost  time — it  is  a 
sign  of  cardiac  disease. 

Heart-sounds  altered  in  duration. — The  first  sound  of  the  heart 
is  prolonged  by  hypertrophy  of  the  ventricles,  and  by  agglu- 
tination of  the  surfaces  of  the  pericardium.  It  is  shortened  in 
dilatation  of  the  ventricles,  and  both  sounds  are  shortened  by 
fatty  degeneration  and  softening  of  the  heart-walls. 

Rest  prolonged. — The  period  of  repose  is  sometimes  prolonged 
by  obstruction  to  the  onward  flow  of  the  blood  into  the  left 
ventricle,  due  to  stenosis  of  the  mitral  orifice. 

Reduplication  of  sounds. — Another  alteration  of  the  rhythm, 
known  as  reduplication,  consists  of  a  repetition  of  one  or  both 
of  the  heart-sounds  during  a  single  pulsation,  so  that  three  or 
four  sounds  may  be  heard  with  each  contraction  of  the  heart. 
Ordinarily  the  right  and  left  sides  of  the  heart  contract  at 
exactly  the  same  time,  and  consequently  the  sounds  which  are 
produced  in  the  two  cannot  be  distinguished  ;  but  occasionally 
there  is  a  slight  interval  between  the  closure  of  the  valves  at 
the  auriculo-ventricular  or  at  the  arterial  orifices  of  the  two 
sides,  so  that  the  sounds  do  not  occur  simultaneously,  and  thus 
the  first  sound  may  be  doubled,  the  second  sound  remaining 
natural ;  or  the  second  sound  may  be  doubled,  the  first  remain- 
ing single  ;  or  both  may  be  doubled. 

This  phenomenon  occurs  in  diseases  of  the  heart,  but  may 
often  be  discovered  in  health,  if  searched  for  with  the  differen- 
tial stethoscope  of  Allison  (Fig.  15,  page  50).  When  occur 
ring  in  disease,  reduplication  is  usually  caused  by  stenosis  of 
the  mitral  orifice  or  incompetence  of  its  valves.  This  gives 
rise  to  increased  tension  in  the  pulmonary  circuit  and  to  abrupt 
closure  of  the  pulmonary  semilunar  valves,  which  thus  slightly 


PHYSICAL   EXAMINATION.  jgj 

anticipate  the  closure  of  the  aortic  valves,  and  cause  reduplica- 
tion of  the  second  sound. 

Reduplication  of  the  first  sound  is  due  to  tardy  closure  of 
the  mitral  valves.  Some  care  will  be  necessary,  to  avoid  mis- 
taking reduplication  for  endocardial  murmurs  which  precede 
or  follow  the  normal  sounds.  Intermission  is  a  characteristic 
of  reduplication.*  In  some  cases  reduplication  is  influenced 
by  the  acts  of  respiration.  In  forced  or  laborious  respiration 
the  first  sound  may  be  reduplicated  at  the  end  of  inspiration 
and  at  the  beginning  of  expiration ;  and  the  second  sound  may 
be  reduplicated  at  the  end  of  expiration  and  at  the  beginning 

of  inspiration. 

. * 

*   Loomis'  Physical  Diagnosis. 


LECTURE    XVIII. 

ABNORMAL  SOUNDS   OF   THE   HEART— CARDIAC 

MURMURS. 

The  abnormal  sounds  heard  over  the  prsecordial  region  are 
denominated  murmurs.  Sometimes  these  are  produced  upon 
the  surface  of  the  heart,  between  the  two  layers  of  the  pericar- 
dium ;  but  most  of  them  originate  within  the  heart.  The  latter 
are  known  as  endocardial  and  the  former  as  exocardial  murmurs. 

PERICARDIAL  FRICTION  SOUNDS. — The  exocardial  or  peri- 
cardial  friction  sounds  or  murmurs  are  produced  by  the  rubbing 
together  of  the  roughened  surfaces  of  the  pericardium,  in  the 
same  manner  that  friction  sounds  are  produced  within  the 
pleura.  These  murmurs  vary  greatly  in  their  intensity  and 
quality.  Sometimes  they  are  very  indistinct,  and  again  they  are 
loud.  In  quality,  they  may  be  grazing,  grating,  rubbing,  creak- 
ing, or  crackling,  like  pleuritic  friction  sounds. 

The  quality  of  an  exocardial  murmur  yields  no  information 
regarding  the  peculiar  condition  of  the  surface  which  produced 
it,  though,  in  the  dry  stage  of  pericarditis,  the  grazing  sound  is 
the  one  most  likely  to  be  heard. 

These  murmurs  may  be  either  single  or  double;  that  is,  they 
may  occur  with  the  systole  or  with  the  diastole  of  the  heart,  or 
with  both.  They  sometimes  accompany  the  valvular  sounds ; 
at  other  times  they  are  independent  of  them.  They  are  always 
superficial  in  character,  seeming  to  be  produced  immediately 
beneath  the  chest-walls.  The  area  over  which  they  can  be 
heard  is  restricted  to  the  praecordial  space.  They  are  generally 
heard  loudest  at  the  junction  of  the  fourth  left  costal  cartilage 
with  the  sternum.  These  murmurs  generally  last  for  only  a 
few  hours,  seldom  longer  than  one  or  two  days,  and  then  dis- 
appear in  consequence  of  the  exudation  of  serum  into  the  peri- 
cardium. As  the  serous  effusion  becomes  absorbed  in  the  latter 
stage  of  pericarditis,  the  friction  murmur  may  reappear. 


ABNORMAL   SOUNDS.  lgQ 

Pericardial  friction  sounds  are  distinguished  from  endocardial 
murmurs,  first,  by  their  superficial  character ;  second,  by  being 
limited  to  the  prascordial  space,  i.  t.,  never  being  transmitted 
to  the  left  of  the  apex,  or  above  the  base  of  the  heart ;  third, 
by  their  being  independent  of  valvular  sounds  ;  and  fourth,  by 
the  variations  in  their  intensity  with  changes  in  the  position  of 
the  patient  When  the  patient  is  in  the  erect  or  in  the  recum- 
bent posture,  the  heart  does  not  approach  so  nearly  to  the 
surface  of  the  chest  as  when  he  is  leaning  well  forward,  and 
therefore  the  sounds  are  not  as  distinct.  In  general,  the 
intensity  is  greater  during  expiration  than  during  inspiration. 

Pericardial  friction  sounds  are  distinguished  from  pleuritic 
friction  sounds  by  their  confinement  to  the  prsecordia,  by  their 
synchronism  with  the  movements  of  the  heart  instead  of  the 
lungs,  and  by  not  being  interrupted  by  temporary  suspension 
of  the  respiratory  act. 

Exceptional. — It  should  be  remembered  that  in  some  cases  of  pleurisy,  attrition  of 
the  fibrous  layer  of  the  pericardium  with  the  inflamed  pleura  gives  rise  to  a  friction 
sound  having  the  same  rhythm  as  the  heart,  and  continuing  while  respiration  is  sus- 
pended. Such  a  sign  is  called  a  cardiac pleural  friction  murmur.  It  is  easily  mis- 
taken for  the  pericardial  murmur,  but  its  cause  should  always  be  suspected  when  other 
signs  of  pleurisy  exist,  especially  if  the  pleurisy  be  associated  with  pneumonia.  This 
friction  sound  differs  from  the  pericardial  murmur  in  the  uniformity  in  intensity  of  the 
successive  sounds,  in  its  limitation  to  the  border  of  the  heart,  and,  in  some  cases,  to  the 
end  of  inspiration  ;  and  in  generally  being  affected  to  a  greater  or  less  degree  by  the 
movements  of  inspiration. 

ENDOCARDIAL  MURMURS  vary  in  their  intensity,  pitch,  and 
quality  ;  but  these  elements  are  of  very  little  importance  from 
a  diagnostic  point  of  view,  as  the  intensity  and  the  pitch  of  the 
sounds  yield  us  no  information  whatever,  and  the  quality  is 
never  characteristic,  except  in  the  presystolic  murmur  due  to 
stenosis  of  the  mitral  orifice. 

These  sounds  are  produced  by  changes  in  the  physical  con- 
dition of  the  heart,  in  which  case  they  are  known  as  organic 
murmurs ;  or  by  changes  in  the  condition  of  the  blood,  when 
they  are  termed  inorganic,  anaemic,  or  hsemic  murmurs. 

Organic  murmurs  are  usually  permanent,  though  not  infre- 
quently they  cease  for  a  considerable  length  of  time ;  and  in 
some  cases  they  may  entirely  disappear.  The  inorganic  mur- 
murs are  transitory,  being  present  for  a  few  hours  or  days,  and 
then  disappearing  permanently,  or  to  recur  after  a  short  inter- 


THE    HEART   AND   AORTA. 

val.  Sometimes  they  come  and  go  while  the  examination  is 
being  made. 

A  murmur  in  the  praecordial  space  indicates  nothing  except 
a  disturbance  of  the  normal  relations  of  the  heart  to  the  blood. 
This  may  be  a  change  in  the  physical  condition  of  the  heart 
itself,  or  in  the  normal  composition  of  the  blood,  or  it 'may 
result  from  irregular  contractions  of  the  cardiac  muscle. 

The  important  things  to  note  regarding  a  murmur  are  :  first, 
the  seat ;  second,  the  rhythm  ;  and  third,  the  quality. 

Seat. — The  seat  of  a  murmur  is  a  limited  space  at  which  it 
can  be  heard  most  distinctly.  The  direction  in  which  the  sound 
is  most  clearly  transmitted  is  also  an  essential  feature  in  diag- 
nosis. 

Rhythm. — In  noting  the  rhythm,  we  observe  the  relation  of 
the  murmur  to  the  systole  and  the  diastole  of  the  ventricles, 
and  consequently  to  the  first  and  second  sounds  of  the  heart ; 
that  is,  whether  it  precedes,  accompanies,  or  follows  one  of 
these. 

Quality. — In  a  few  instances,  the  peculiar  characteristics  of 
the  sound  itself  are  important.  Some  murmurs  are  grating, 
others  blowing  or  rushing  in  quality,  and  others  are  harsh,  or 
soft,  or  musical.  A  murmur  may  have  man}-  of  these  character- 
istics at  different  times  without  any  appreciable  change  in  the 
conditions  which  produce  it. 

Whenever  we  hear  an  abnormal  sound  in  the  .prascordial 
space,  we  should  ascertain,  by  careful  examination,  its  point  of 
maximum  intensity,  that  is,  at  what  part  of  this  space  it  may 
be  heard  most  distinctly  ;  and  whether  it  is  synchronous  with 
either  the  contraction  or  the  dilatation  of  the  cardiac  cavities, 
and  depends  upon  a  "  fluid  vein  "*  in  the  current  of  blood, 
through  the  valvular  orifices  ;  or  whether  it  is  produced  out- 
side the  heart.  As  the  majority  of  abnormal  cardiac  sounds 
are  produced  within  the  heart,  the  presumption  is  always  in 
favor  of  a  murmur  being  endocardial ;  and  if  we  should  find  it 
comparatively  deep-seated,  and  synchronous  with  the  systole 
or  the  diastole  of  the  ventricles,  and  transmitted  to  the  left  of 
the  apex,  or  above  the  base  of  the  heart,  we  may  safely  con- 
clude that  it  belongs  to  this  class. 

*  M.  A.  Chaveau,  Comptes  Rendus  de  I'Acade'mie  des  Sciences,  1858. 


ABNORMAL   SOUNDS.  JQJ 

When  we  remember  that  nearly  all  endocardial  murmurs 
are  produced  at  one  of  the  valvular  orifices,  and  that  these 
approximate  so  closely  to  each  other  that  a  circle  half  an  inch 
in  diameter  may  include  a  portion  of  each,  it  is  at  once  appar- 
ent that  it  must  be  impossible  to  distinguish  between  different 
endocardial  sounds,  by  listening  for  them  directly  over  their 
point  of  origin.  We  must,  therefore,  take  special  measures  to 
separate  them  from  each  other. 

Sound  loses  its  intensity  by  passing  from  one  medium  to 
another,  as  will  occur  in  the  passage  of  sound  from  one  cavity 
of.  the  heart  to  another,  and  any  sound  produced  by  fluid  in 
motion  is  transmitted  in  the  direction  of  the  current  which 
causes  it.  A  knowledge  of  these  two  facts  will  aid  us  greatly 
in  differentiating  between  endocardial  sounds.  We  will  find 
that,  as  a  rule,  sounds  produced  in  any  of  the  cavities  of  the 
heart,  or  transmitted  into  them,  are  best  heard  over  the  space 
where  that  cavity  is  most  superficial.  For  example,  the  only 
point  at  which  the  left  ventricle  impinges  directly  on  the  chest- 
wall  is  where  the  apex-beat  is  felt;  and  we  find  that  murmurs 
produced  at  its  auricular  orifice  are  best  heard  at  this 
spot,  while  those  at  the  tricuspid  orifice  are  most  distinct 
over  that  portion  of  the  right  ventricle  which  is  superficial. 
The  murmurs  at  the  aortic  and  pulmonary  orifices  are  respect- 
ively heard  with  the  greatest  distinctness  where  these  arteries 
approach  nearest  the  chest-wall. 

Some  of  the  endocardial  murmurs,  however,  are  produced 
by  blood  flowing  in  an  abnormal  direction.  Therefore,  the 
areas  in  which  murmurs  produced  at  the  various  orifices  are 
most  distinct,  will  not  always  exactly  correspond  to  the  positions 
in  which  the  normal  sounds  are  loudest. 

Before  examining  the  heart  by  auscultation,  we  should  first 
ascertain  its  superior  and  lateral  limits  by  percussion  or 
by  auscultatory  percussion ;  and  either  by  these  methods  or  by 
palpation,  determine  the  position  of  the  apex. 

M  ITRAL  AREA.— The  mitral  area,  as  the  space  is  named  where 
the  mitral  sounds  may  be  heard  with  maximum  intensity,  cor- 
responds to  a  circle  two  inches  in  diameter,  which  includes 
the  apex  of  the  heart  (A,  Fig.  27).  If  this  organ  is  in  its 
normal  position,  the  circle,  as  shown  in  the  diagram,  will  have 
its  centre  near  the  normal  position  of  the  apex-beat;  but  if, 


1^2  THE    HEART   AND   AORTA. 

from  enlargement  or  other  causes,  the  heart  is  displaced  to  the 
left,  the  position  of  this  circle  should  be  correspondingly 
changed. 

Mitral  murmurs,  if  caused  by  regurgitation,  are  also  heard 
diffused  for  a  distance  varying  from  one  to  three  inches,  to  the 
left  of  the  apex.  Often  they  may  be  heard  behind,  along  the 
left  side  of  the  sixth  and  seventh  dorsal  vertebras,  with  nearly 
the  same  intensity  as  in  front ;  sometimes  they  may  be  heard 
in  this  position  when  they  are  not  distinct  in  front. 


FIG.  27. — Areas  of  endocardia!  murmurs.  A,  mitral  area.  B,  aortic  area.  C,  tri- 
cuspid  area.  D.  pulmonary  area. 

Care  must  be  taken  not  to  confound  mitral  murmurs  with 
aortic  regurgitant  murmurs,  which  are  occasionally  heard  at 
the  lower  angle  of  the  left  scapula,  and  in  the  left  axillary 
region;  or  with  aneurismal  murmurs,  which  may  also  be  heard 
along  the  left  side  of  the  spinal  column,  in  the  same  position  as 
the  mitral  regurgitant  murmur. 

A  mitral  regurgitant  murmur  differs  from  an  aneurismal 
murmur  in  being  heard  only  between  the  fifth  and  the  eighth 
dorsal  vertebrae.  The  aneurismal  murmur  may  be  heard  above 
the  fifth  vertebra,  and  with  diminished  intensity,  below  the 
eighth  vertebra,  as  well  as  between  the  two. 

An  aortic  direct  murmur,  heard  behind,  should  not  be   mis- 


ABNORMAL   SOUNDS.  Ig, 

taken  for  mitral  regurgitant,  since  it  is  heard  loudest  above  the 
lower  border  of  the  fifth  dorsal  vertebra. 

Mitral  regurgitant  murmurs  may  sometimes  disappear,  even 
though  due  to  organic  lesions.  In  such  cases,  accentuation  of 
the  second  sound  at  the  pulmonary  orifice  may  be  the  only 
abnormal  sign  remaining. 

If  a  mitral  murmur  is  obstructive,  or  direct,  i.  e.,  due  to 
stenosis  of  the  mitral  orifice,  it  will  be  heard  at  the  apex,  but 
will  not  be  distinctly  transmitted  to  the  left,  and  it  will  not  be 
heard  behind. 

You  must  bear  in  mind  that,  in  speaking  of  the  areas  of 
murmurs,  we  refer  only  to  the  positions  at  which  they  may 
be  heard  with  the  greatest  intensity.  Sometimes  a  mitral  mur- 
mur may  be  heard  over  the  whole  prascordial  region,  or  even 
over  the  entire  chest,  but  its  point  of  maximum  intensity  will 
correspond  to  the  area  which  we  have  just  described. 

TRICUSPID  AREA. — The  area  of  tricuspid  murmurs  is  limited 
to  the  triangular  space  (C,  Fig.  27)  where  the  right  ventricle 
is  superficial.  These  murmurs  are  ordinarily  loudest  over  the 
xiphoid  cartilage,  or  along  the  left  border  of  the  sternum,  at 
the  junction  of  the  sixth  or  the  seventh  costal  cartilage  ;  and 
they  are  seldom  audible  above  the  third  rib.  This  latter  feature 
distinguishes  them  from  aortic  and  from  pulmonic  murmurs. 
When  the  heaVt  is  hypertrophied  or  dilated,  their  intensity  will 
sometimes  be  greatest  at  the  junction  of  the  fourth  costal 
cartilage  with  the  sternum.  These  murmurs  are  superficial  in 
character  as  compared  with  those  occurring  upon  the  left  side 
of  the  heart.  If  transmitted  in  any  direction,  they  will  be 
heard  more  distinctly  to  the  right  than  to  the  left  of  the  para- 
sternal  line. 

PULMONARY  AREA. — Pulmonic  murmurs  are  heard  most 
distinctly  directly  over  the  pulmonary  artery.  The  area  of 
these  sounds  corresponds  to  a  small  circle  about  an  inch  in 
diameter,  located  just  above  the  third  costal  cartilage  at  the  left 
border  of  the  sternum,  and  inclosing  the  pulmonary  artery 
(D,  Fig.  27,  page  192).  These  sounds  are  never  heard  in  the 
carotid  and  subcla  vian  arteries.  If  due  to  regurgitation  through 
the.  pulmonary  valves  into  the  right  ventricle,  they  may  be 
most  intense,  an  inch  or  an  inch  and  a  half  below  this  area, 
near  the  left  margin  of  the  sternum.  They  are  not  heard  at  the 

'3 


I94  THE  HEART  AND  AORTA. 

apex,  and  this  distinguishes  them  from  some  aortic  murmurs. 
These,  like  the  tricuspid  murmurs,  are  comparatively  superficial. 

AORTIC  MURMURS. — The  area  of  aortic  murmurs  cannot  be 
so  sharply  denned  as  the  areas  of  the  murmurs  we .  have  just 
described.  These  sounds  are  usually  loudest  in  the  second 
intercostal  space  of  the  right  side,  where  the  aorta  approaches 
most  closely  to  the  thoracic  walls ;  or  along  the  right  margin 
of  the  sternum  from  the  second  to  the  fourth  rib;  but  they 
are  often  heard  over  the  whole  sternum  (B,  Fig.  27,  page  192). 

Aortic  murmurs  are  propagated  to  the  carotid  or  subclavian 
arteries,  and  are  frequently  heard  best  in  these  localities.  Oc- 
casionally they  are  louder  in  the  pulmonary  area  than  at  any 
other  point.  In  such  instances  they  are  distinguished  from 
pulmonary  murmurs  by  being  heard  also  in  the  arteries  at  the 
base  of  the  neck.  Aortic  murmurs  are  often  heard  behind, 
along  the  left  side  of  the  third  and  fourth  dorsal  vertebrae,  and 
with  diminishing  intensity  for  a  considerable  distance  down  the 
spine.  They  are  frequently  very  distinct  at  the  apex  of  the 
heart. 

Aortic  regurgitant  murmurs  are  often  loudest  over  the  lower 
part  of  the  sternum,  though  we  expect  to  find  them  most  dis- 
tinct a  short  distance  below  the  aortic  valves.  These  murmurs 
are  frequently  audible  in  the  left  axillary  region,  and  at  the 
lower  angle  of  the  scapula.  The  patient  may  often  hear  them 
himself,  especially  when  lying  down. 

Exceptional. — Aortic  murmurs  may  sometimes  be  heard  over  the  arteries  when  they 
are  not  distinct  at  the  base  of  the  heart.  At  other  times  they  can  be  heard  at  the  base 
of  the  heart  only;  and  still  again,  they  may  be  distinct  over  the  entire  pnecordial 
region. 

Regurgitant  aortic  murmurs  are  frequently  heard  in  all  the 
arteries  which  are  accessible  to  auscultation.  It  should  be 
remembered  that  the  aortic  murmurs  are  the  only  ones  that 
may  be  heard  above  the  clavicles. 

Both  the  obstructive  and  the  regurgitant  aortic  murmurs 
vary  much  in  intensity.  Sometimes  it  is  necessary  to  listen 
intently  in  order  to  hear  them  at  all.  In  other  cases  they  are 
so  loud  that  they  may  be  heard  at  some  distance  from  ^the 
patient. 

RHYTHM. — The  rhythm  of  a  murmur  refers  to  the  relation 


CAUSES   OF   ENDOCARDIAL   MURMURS.  mj 

which  it  bears  to  the  cardiac  pulsation,  and  consequently  to  the 
first  and  second  sounds  of  the  heart.  In  determining  the 
rhythm  of  a  murmur,  we  must  first  ascertain  which  is  the  first 
and  which  the  second  sound  of  the  heart.  This  will  not  be  a 
difficult  task  if  the  heart  is  pulsating  slowly,  and  both  sounds 
are  distinct ;  for  we  know  that  the  first  sound  is  the  louder 
and  longer,  and  that  it  is  associated  with  the  impulse  of  the 
apex  against  the  chest-wall.  In  some  instances  only  one  of  the 
valvular  sounds  can  be  heard  at  the  apex  or  at  the  base,  and  in 
such  cases  a  murmur  would  very  naturally  be  mistaken  for  the 
other  sound.  In  every  case  of  doubt  we  must  feel  for  the  ca- 
rotid pulse,  which  is  always  synchronous  with  the  first  sound 
of  the  heart,  and  will  therefore  enable  us  to  determine  the 
rhythm  of  the  murmur. 

QUALITY. — The  quality  of  endocardial  murmurs  gives  us  no 
information  regarding  their  place  of  origin  or  the  conditions 
which  produce  them,  excepting  in  cases  of  presystolic  mitral 
murmurs,  which  will  be  presently  described,  and  anaemic  mur- 
murs, which  are  always  soft  in  character. 

CAUSES  OF  ENDOCARDIAL  MURMURS. 

PRESYSTOLIC,  MITRAL,  AND  TRICUSPID  MURMURS.— These 
murmurs,  preceding  as  they  do  the  first  sound  of  the  heart, 
must  occur  while  the  blood  is  passing  from  the  auricles  into 
the  ventricles,  and  while  the  valves  are  thrown  out  upon  the 
current  (Fig.  28).  They  are  always  caused  by  narrowing 
(stenosis)  of  the  auriculo-ventricular  orifice,  which  obstructs  the 
onward  flow  of  blood.  Such  a  murmur,  if  produced  upon  the 
left  side,  will  be  loudest  at  the  apex,  but  it  will  not  be  trans- 
mitted to  the  left  of  the  apex,  and  it  cannot  be  heard  behind. 
It  is  called  a  mitral  presystolic  or  obstructive  murmur.  This  is 
perhaps  the  only  murmur  where  the  quality  of  the  sound  is  of 
any  special  diagnostic  value.  According  to  Balfour,  the  quality 
of  these  murmurs  is  characteristic,  though  not  exactly  the  same 
in  all  cases.  It  may  be  quite  accurately  represented  by  vocal- 
izing the  symbols  "RrrborVoo  t."  If  a  murmur  which 
precedes  the  first  sound  of  the  heart  is  produced  upon  the 
right  side — which  is  extremely  uncommon— it  is  called  a  t 
cuspid  obstructive  murmur,  and  its  area  is  limited  to  the  tn- 


jg6  THE  HEART  AND  AORTA. 

angular  space  C,  at  the  lower  portion  of  the  sternum— Fig. 
27,  page  192). 

SYSTOLIC  MURMURS. — A  murmur  accompanying  or  following 
the  first  sound  of  the  heart,  must  occur  with  the  contraction  of 
the  ventricles,  the  closure  of  the  auriculo-ventricular  valves, 
and  the  propulsion  of  the  blood  from  the  ventricles  into  the 
arteries.  It  may  be  due  to  lesions  at  any  of  the  valvular  ori- 
fices. 


FIG.  28. — Auricular  Systole.     A,  C,  contracted  auricles.     B,  D,  dilated  ventricles. 
Mitral  and  tricuspid  valves  open  ;  semilunar  valves  closed. 

MITRAL  SYSTOLIC  OR  REGURGITANT  MURMUR. — This  mur- 
mur is  produced  at  the  mitral  orifice,  and  is  due  to  thickening, 
corrugation,  or  adhesions  of  the  valves,  which  prevents  them 
from  perfectly  closing  the  orifice,  and  thus  allows  the  blood  to 
regurgitate  into  the  left  auricle.  This  murmur  is  generally  soft 
and  blowing,  and  it  may  be  musical  in  quality  ;  it  will  be  loud- 
est in  the  mitral  area.  It  will  be  transmitted  to  the  left  of  the 
apex ;  and  may  be  heard  posteriorly  along  the  left  side  of  the 
spinal  column  from  the  fifth  to  the  eighth  dorsal  vertebra. 
It  is  seldom  heard  in  this  situation  with  the  same  intensity  as 
at  the  apex,  but  occasionally  it  is  distinct  behind  when  it  is  not 
audible  in  front.  If  a  mitral  murmur  is  caused  simply  by 
roughening  of  the  ventricular  surface  of  the  valves,  it  will  not 
be  heard  beside  the  sixth  or  seventh  dorsal  vertebra,  though 
it  may  be  heard  about  the  inferior  angle  of  the  scapula,  and 
in  the  left  axillary  region. 


CAUSES   OF   ENDOCARDIAL   MURMURS. 


197 


TRICUSPID  SYSTOLIC  OR  REGURGITANT  MURMUR. — This 
murmur  will  be  heard  in  the  tricuspid  area  ;  and  if  transmitted 
in  either  direction  it  will  be  louder  to  the  right  .than  to  the  left. 
It  will  not  be  heard  at  the  apex  distinctly,  and  never  to  the  left 
of  the  apex  or  behind.  This  murmur  is  generally  of  a  blow- 
ing quality. 

AORTIC  SYSTOLIC,  OBSTRUCTIVE,  OR  DIRECT. — If  this  mur- 
mur is  of  organic  origin,  it  will  be  caused  by  constriction  of 
the  aortic  semilunar  valves,  or  by  roughening  of  their  ventric- 
ular surfaces,  or  possibly  by  disease  of  the  artery.  It  will  be 
produced  while  the  blood  is  passing  from  the  ventricles  into 
the  arteries  (Fig.  29),  and  it  will  be  heard  in  the  aortic  area 


FIG.  29.— Systole  of  the  ventricles.     A,  C,  auricles  dilating.     B,  D,  ventricles  contract- 
ing.    Semilunar  valves  open  ;  mitral  and  tricuspid  valves  closed. 

over  the  second  intercostal  space  of  the  right  side,  or  over 
other  portions  of  the  sternum  as  shown  by  the  space  B,  Fig. 
27,  page  192.  It  will  also  be  heard  in  the  arteries  of  the  neck, 
and  frequently  it  will  be  audible  posteriorly  at  the  left  of  the 
third  and  fourth  dorsal  vertebras,  and  possibly  with  diminished 
intensity  farther  down  the  spine. 

If  this  murmur  is  loudest  over  the  pulmonary  artery,  as 
occasionally  happens,  it  may  be  distinguished  from  murmurs 
produced  at  the  pulmonary  orifice,  by  the  fact  that  it  is  trans- 
mitted to  the  carotid  and  subclavian  arteries. 

PULMONARY  SYSTOLIC,  OBSTRUCTIVE,  OR  DIRECT.— A  sys- 


jog  THE  HEART  AND  AORTA. 

tolic  murmur  produced  at  the  pulmonary  orifice,  is  likely  to 
be  a  hsemic  murmur;  but  if  of  organic  origin,  it  will  be  due  to 
obstruction  similar  to  that  just  described  as  occurring  at  the 
aortic  valves.  These  murmurs  are  sometimes  caused  by  press- 
ure on  the  artery  by  enlarged  glands;  or  by  constriction  of  the 
artery  from  pleuritic  adhesions,  or  fibroid  phthisis  with  con- 
traction of  the  lung.  Such  a  murmur  will  be  heard  most  dis- 
tinctly in  the  pulmonary  area(D,  Fig.  27,  page  192),  and  it  will 
not  be  heard  in  the  arteries  at  the  base  of  the  neck. 

A  murmur  accompanying  or  following  the  second  sound  of 
the  heart  occurs  with  the  diastole  of  the  ventricles  and  must 
be  due  to  regurgitation  of  blood  from  the  arteries  through  the 
semilunar  valves,  either  on  the  right  or  on  the  left  side. 

AORTIC  DIASTOLIC,  OR  REGURGITANT. — If  a  murmur,  accom- 
panying or  following  the  second  sound  of  the  heart,  occurs  at 
the  aortic  orifice,  it  will  be  due  to  regurgitation  of  blood  from 
the  artery  into  the  left  ventricle.  It  will  generally  be  soft  and 
blowing  in  character,  though  it  may  be  harsh.  It  will  be  heard 
in  the  aortic  area,  but  usually  most  distinctly  a  short  distance 
below  the  valves ;  it  will  be  propagated  down  the  sternum  and 
it  may  sometimes  be  loudest  at  the  ensiform  appendix. 

Exceptional. — In  some  instances  such  murmurs  are  very  distinct  at  the  apex,  in  the 
axillary  region  about  the  lower  angle  of  the  left  scapula,  or  over  all  superficial  arteries. 

PULMONARY  DIASTOLIC,  OR  REGURGITANT. — If  produced  at 
the  pulmonary  orifice,  a  diastolic  murmur  must  be  due  to  regur- 
gitation through  the  pulmonary  valves.  These  murmurs  are 
extremely  rare. 

When  such  a  murmur  occurs  it  will  be  heard  in  the  pulmo- 
nary area,  or  an  inch  or  inch  and  a  half  below  this  space,  and 
it  will  not  be  transmitted  to  the  arteries  or  to  the  lower  part 
of  the  sternum.  From  this  latter  fact  it  may  easily  be  distin- 
guished from  a  similar  murmur  at  the  aortic  orifice. 

From  what  has  been  said,  you  will  observe  that  we  may  have 
eight  distinct  valvular  murmurs,  four  of  which  are  obstructive 
and  four  regurgitant.  However,  two  of  these,  viz.,  the  regurgi- 
tant  pulmonary,  and  the  obstructive  tricuspid  murmurs,  are  so 
very  rare  that  their  existence  is  doubted  by  many  skilled  diag- 
nosticians. Regurgitant  tricuspid  murmurs  are  rare,  except 
as  the  consequence  of  disease  of  the  left  side  of  the  heart,  which 


VENTRICULAR    MURMURS. 

lyy 

gives  rise  to  such  dilatation  of  the  right  ventricle  that  the  auri- 
culo-ventricular  orifice  becomes  too  large  to  be  closed  by  the 
tricuspid  valves. 

We  may  have  two  or  more  of  these  sounds  combined  in  any 
case  ;  thus  it  is  not  uncommon  to  obtain  a  mitral  regurgitant 
murmur  associated  with  an  aortic  obstructive,  and  perhaps 
also  with  an  aortic  regurgitant;  or  we  may  have  both  the 
mitral  obstructive  and  regurgitant,  with  the  aortic  obstructive 
and  regurgitant. 

Murmurs  are  common  in  the  left  side  of  the  heart,  but  rare 
in  the  right  side. 

According  to  my  observation,  the  various  murmurs  occur 
in  the  following  order  of  frequency  :  mitral  regurgitant,  aortic 
regurgitant,  aortic  obstructive,  mitral  obstructive  or  presystolic, 
and  tricuspid  regurgitant. 

VENTRICULAR  MURMURS. 

There  are  certain  murmurs  occasionally  heard  in  .the  prx- 
cordial  region,  which  are  neither  of  valvular  nor  of  haemic 
origin.  They  are  most  frequent  during  the  active  stage  of 
endocarditis,  but  they  also  occur  in  chronic  endocarditis. 
They  sometimes  precede  and  sometimes  follow  endocarditis, 
and  in  some  instances  they  are  apparently  induced  by  simple 
irritability  of  the  heart.  They  occur  with  the  first  sound  of 
the  heart,  and  are  loudest  at  the  apex.  These  murmurs  seem 
to  be  caused  by  roughening  of  the  endocardium  or  of  the 
chordae  tendinas,  or  by  irregular  contraction  of  the  muscular 
fibres  of  the  ventricles.  They  are  of  comparatively  rare  oc- 
currence, and  then  are  usually  mistaken  for  valvular  murmurs. 
They  may  be  distinguished  from  the  latter  by  their  rhythm 
and  by  their  seat.  These  murmurs  are  most  likely  to  be  con- 
founded with  mitral  regurgitant,  and  aortic  or  pulmonary 
obstructive  murmurs. 

A  ventricular  murmur,  though  heard  at  the  apex  with  the 
first  sound  of  the  heart,  is  never  transmitted  to  the  left.  Thus 
it  is  distinguished  from  the  mitral  regurgitant  murmur,  which 
possesses  the  same  rhythm.  A  ventricular  murmur  is  never 
heard  above  the  base  of  the  heart,  and  thus  is  distinguished 
from  aortic  and  pulmonary  murmurs. 


LECTURE    XIX. 
MURMURS,  Continued— SPHYGMOGRAPH. 

In  order  to  more  clearly  define  the  difference  between  these 
various  murmurs,  it  will  be  profitable  to  enumerate  again  their 
distinctive  features,  as  concisely  as  possible,  with  the  addition 
of  a  few  hints  concerning  their  differential  diagnosis. 

Mitral  obstructive  murmurs  precede  the  first  sound  of  the 
heart.  They  are  heard  at  the  apex,  but  are  not  transmitted  to 
the  left,  or  into  the  arteries,  and  they  are  not  heard  behind. 
The  rhythm  of  these  murmurs  is  to  be  ascertained  by  placing 
the  finger  over  the  carotid  pulse.  Their  quality  is  character- 
istic, and  may  be  represented  by  vocalizing  the  symbols  R  r  r  b 
or  V  o  o  t. 

Mitral  regurgitant  murmurs  accompany  or  replace  the  first 
sound  of  the  heart.  They  are  loudest  at  the  apex,  but  are 
transmitted  to  the  left,  and  may  often  be  heard  behind,  beside 
the  sixth  and  seventh  dorsal  vertebrae,  if  the  chest-walls  are 
not  too  thick.  They  are  distinguished  from  the  mitral  obstruct- 
ive murmurs  by  accompanying  or  following  the  first  sound 
instead  of  preceding  it,  and  by  being  transmitted  to  the  left  of 
the  apex.  They  are  distinguished  from  the  aortic  obstructive 
murmurs,  which  have  the  same  rhythm,  and  may  sometimes  be 
heard  at  the  apex,  by  being  propagated  to  the  left  of  the  apex, 
by  not  being  transmitted  into  the  arteries,  and  by  their  limita- 
tion behind  to  the  mitral  area.  They  are  distinguished  from 
tricuspid  regurgitant  murmurs  by  their  seat,  and  by  being 
transmitted  to  the  left  instead  of  to  the  right.  They  are  distin- 
guished from  aortic  and  from  pulmonary  regurgitant  murmurs 
by  occurring  with  the  first  sound  of  the  heart  instead  of  with 
the  second. 

Aortic  obstructive  murmurs  are  usually  best  heard  in  the  aortic 
area,  or  over  the  upper  part  of  the  sternum,  and  in  the  carotid 
and  subclavian  arteries.  They  always  occur  with  the  first 
sound  of  the  heart. 


CAUSES   OF   ENDOCARDIAL   MURMURS,:  2OI 

When  they  are  loudest  in  the  pulmonary  area,  they  may  be 
distinguished  from  pulmonic  murmurs  by  being  transmitted 
into  the  arteries.  When  heard  at  the  apex,  they  may  be  distin- 
guished from  mitral  murmurs  by  not  being  transmitted  to  the 
left,  and  by  being  propagated  into  the  arteries. 

Aortic  regurgitant  murmurs  are  usually  most  distinct  over  the 
lower  part  of  the  sternum ;  but  they  are  heard  also  over  the 
aorta  and  its  main  branches.  They  occur  with,  or  following  the 
second  sound  of  the  heart.  These  murmurs  are  not  likely  to 
be  confounded  with  any  other  murmur,  except  the  pulmonary 
regurgitant,  which  is  so  exceedingly  rare  that  it  may  here  be 
left  out  of  the  question. 

The  tricuspid  obstructive  murmur  is  so  rare  that  it  merits  no 
description. 

The  tricuspid  regurgitant  murmur  seldom  occurs,  except  as  a 
result  of  cardiac  disease  of  the  left  side.  When  present,  it 
will  be  loudest  in  the  tricuspid  area  and  will  be  transmitted 
toward  the  right  of  the  sternum.  It  will  not  be  distinct  at  the 
apex  of  the  heart ;  nor  will  it  be  heard  posteriorly  ;  and  it  will 
be  associated  with  pulsations  in  the  jugular  veins.  These 
features  at  once  distinguish  it  from  a  mitral  murmur. 

The  pulmonary  obstructive  murmur  will  be  heard  in  the  pul- 
monary area,  that  is,  the  second  intercostal  space  of  the  left  side 
close  to  the  sternum,  and  will  occur  with  the  first  sound  of  the 
heart.  It  can  only  be  distinguished  from  aortic  murmurs, 
which  are  sometimes  heard  in  the  same  locality,  by  the  fact 
that  it  is  not  heard  in  the  arteries,  above  the  clavicles. 

The  pulmonary  regurgitant  murmur,  like  the  tricuspid  obstruct- 
ive, hardly  merits  present  description.  When  it  occurs,  it  may 
be  heard  in  the  pulmonary  artery,  and  about  an  inch  or  an  inch 
and  a  half  lower.  It  occurs  with  the  second  sound. 

Ventricular  murmurs  are  heard  with  the  first  sound  at  the 
apex,  and  are  not  transmitted  beyond  the  limits  of  the  heart ; 
this  will  distinguish  them  from  all  other  systolic  murmurs 
excepting  the-tricuspid  regurgitant,  which  is  not  heard  at  the 
apex. 

Beside  the  ventricular  murmurs  resulting  from  endocarditis,  there  are  rare  adventi- 
tious sounds  which  might  appropriately  be  called  ventricular  murmurs,  which  are  ap- 
parently produced  by  irregular  contractions  of  the  muscular  fibres  of  the  heart.  They 
are  likely  to  be  heard  for  two  or  three  pulsations  and  then  to  disappear,  to  recur  again 
after  a  few  moments. 


CCLLIEGI 

I-  K  \ 


202  THE  HEART  AND  AORTA. 

Sometimes  endocardial  murmurs  are  produced  by  dilatation 
of  the  ventricles,  which  prevents  perfect  closure  of  the  mitral 
valves.  Such  murmurs  have  been  termed  Curable  mitral  regur- 
gitant  murmurs,  as  they  disappear  when  the  tonicity  of  the 
muscular  fibre  has  become  sufficiently  restored  to  contract  the 
cavities  to  their  original  size.  These  murmurs  are  probably 
caused  by  dilatation  of  the  ventricles  without  a  corresponding 
elongation  of  the  musculi  papillares  in  consequence  of  which 
the  chordae  tendinas  are  too  short  to  allow  the  valves  to  close. 

Frequently  in  the  examination  of  the  heart,  impure  sounds  are 
obtained,  which  closely  resemble  faint  valvular  murmurs. 
These  are  not  constant,  but  may  come  and  go  during  the  exam- 
ination. They  are  generally  heard  just  at  the  end  of  inspira- 
tion, and  they  usually  cease  when  respiration  is  suspended. 

CONGENITAL  MURMURS. — Imperfect 'closure  of  the  foramen 
ovale  allows  the  blood  to  pass  directly  from  the  right  into  the 
left  auricle,  and  this  occasions  a  murmur  which  is  audible  over 
the  base  of  the  heart.  It  is  heard  with  the  systole  of  the  ven- 
tricles, and  is  not  transmitted  into  the  arteries,  or  to  the  left  of 
the  apex.  It  may  thus  be  distinguished  from  aortic  and  mitral 
murmurs.  This  murmur  always  occurs  in  early  life,  and  is 
associated  with  a  cyanotic  appearance  of  the  countenance. 
When  the  child  reaches  the  age  of  ten  or  twelve  years,  other 
abnormal  sounds  usually  supervene. 

HyEMic  MURMURS. — Another  variety  of  adventitious  sounds 
is  due  to  the  composition  of  the  blood  instead  of  to  changes  in 
anatomical  condition  of  the  heart.  These  are  termed  anasmic, 
hasmic,  or  inorganic  murmurs.  They  are  generally  most  dis- 
tinct over  the  aorta,  and  are  diffused  through  the  vessels  of  the 
neck.  Sometimes  they  may  be  heard  in  the  second  intercostal 
space  of  the  left  side,  about  an  inch  and  a  half  to  the  left  of  the 
pulmonary  artery.  They  are  always  systolic. 

The  hsemic  murmurs  which  are  produced  in  the  aorta  are 
due  simply  to  change  in  the  composition  of  the  blood.  Those 
heard  to  the  left  of  the  pulmonary  artery  seem  to  be  produced 
by  slight  dilatation  of  the  left  ventricle,  with  consequent  im- 
perfect closure  of  the  mitral  valves,  and  more  or  less  regurgi- 
tation  of  blood  into  the  auricle. 

These  murmurs  are  inconstant,  often  coming  and  going  dur- 


K  /  I  r. 


ANOMALOUS   HEART-SOUNDS.  2O- 

ing-  tie  examination,  and  finally  permanently  disappearing,  as 
proper  treatment  removes  the  anaemic  condition  of  the  blood. 

They  are  distinguished  from  organic  murmurs  by  the  follow- 
ing characteristics  :  they  always  accompany  the  first  sound  of 
the  heart;  they  are  soft  and  blowing  in  character;  those 
which  are  arterial  may  be  heard  over  many  of  the  aortic 
branches  ;  and  those  which  are  mitral  may  be  heard  a  variable 
distance  to  the  left  of  the  pulmonary  artery.  They  are  incon- 
stant and  likely  to  be  present  when  the  heart's  action  is  rapid, 
but  absent  when  it  is  slow.  These  murmurs  are  also  attended 
by  the  symptoms  and  signs  of  general  anasmia.  Except  in 
complicated  cases,  they  are  not  associated  with  the  signs  of 
other  cardiac  disease.  They  are  incapable  of  supplanting  the 
normal  heart-sounds,  or  even  of  making  them  less  distinct. 
They  are  usually  associated  with  the  venous  hum. 

ANOMALOUS  HEART-SOUNDS. 

In  rare  instances,  sounds  may  be  heard  over  the  praecordial 
space,  which  are  not  endocardial,  and  are  not  produced  be- 
tween the  two  surfaces  of  the  pericardium.  These  result 
from  the  action  of  the  heart  upon  the  lungs,  and  they  usually 
cease  when  the  respirations  are  suspended. 

With  the  systole  of  the  ventricles,  a  loud  blowing  sound  may 
be  occasioned  by  a  large  pulmonary  cavity  situated  near  the 
heart.  More  or  less  distinct  blowing  sounds  are  frequently 
heard  when  the  systole  of  the  heart  occurs  just  at  the  end  of 
inspiration.  These  cease  when  the  patient  holds  his  breath. 

Friction  sounds  may  be  produced  by  the  action  of  the  heart 
upon  the  overlying  pleura.  Generally  these  may  be  easily  dis- 
tinguished from  pericardial  friction  sounds  by  their  seat, 
and  by  their  disappearance  with  the  cessation  of  respiration. 
The  pericardial  friction  sounds  are  heard  most  distinctly  along 
the  left  border  of  the  sternum ;  but  sounds  produced  within  the 
pleura  by  the  action  of  the  heart  are  heard  most  clearly  over 
the  outer  portion  of  the  mammary  region.  They  are  also 
usually  associated  with  friction  sounds  over  other  portions  of 
the  left  lung.  Ordinary  friction  sounds,  due  to  pleurisy,  are 
sometimes  observed  in  the  prsecordial  region ;  but  these  dis- 
appear when  the  patient  holds  his  breath. 


THE   HEART   AND   AORTA. 

The  sounds  caused  by  the  action  of  the  heart  upon  the  lungs 
occasionally  resemble  bronchial  rales ;  but  as  these  are  limited 
to  the  praecordial  space,  they  are  not  likely  to  be  mistaken  for 
sounds' due  to  pulmonary  disease. 

SUBCLAVIAN  MURMURS. 

Subclavian  murmurs  are  often  heard  just  beneath  the  clavicle, 
at  the  outer  portion  of  the  infraclavicular  region,  and  more 
frequently  upon  the  left  than  upon  the  right  side.  Most  of 
these  seem  to  me  to  be  produced  by  the  pressure  of  the  stetho- 
scope ;  but  murmurs  frequently  occur  in  this  locality,  and  over 
other  parts  of  the  subclavian  artery,  which  are  not  due  to 
external  causes.  They  are  supposed  to  result  from  pressure 
upon  the  artery,  either  by  consolidated  lung  tissue  or  by  cica- 
tricial  bands  resulting  from  pleurisy  ;  but  their  exact  cause  is 
not  known.  They  are  most  frequently  associated  with  con- 
solidation of  the  apex  of  the  lung. 

VENOUS  SIGNS. 

CONGESTION. — Congestion  of  the  superficial  veins  of  the  neck 
and  upper  part  of  the  trunk  is  a  sign  of  cardiac  or  pulmonary 
disease,  and  of  aortic  aneurism  or  other  intrathoracic  tumors. 
The  condition  is  caused  by  direct  pressure  on  the  veins,  or  by 
increase  in  the  intrathoracic  pressure  from  pulmonary  disease, 
and  consequent  interference  with  the  return  of  blood  to  the 
heart.  It  is  always  most  noticeable  when  the  patient  is  in  the 
recumbent  position. 

This  turgescence  may  be  either  temporary  or  permanent. 
If  temporary,  it  is  most  marked  in  expiration,  or  after  attacks 
of  coughing,  and  it  will  entirely  disappear  upon  deep  inspira- 
tion. 

TEMPORARY  TURGESCENCE  OF  THESE  VEINS  is  generally  due 
to  congestion  of  the  pulmonary  circuit,  resulting  from  disease 
of  the  lungs,  which  compresses  the  capillaries,  and  consequently 
causes  distention  of  the  pulmonary  arteries  and  of  the  right 
side  of  the  heart,  and,  through  it,  of  the  descending  vena  cava 
and  its  branches. 

PERMANENT  TURGESCENCE  most  commonly  results  from  dis- 
ease of  the  mitral  valves,  which  either  obstructs  the  onward 


VENOUS   SIGNS.  2oc 

current  of  blood  into  the  ventricle,  or  allows  free  regurgitation 
into  the  auricle.  This  gives  rise  to  congestion  of  the  pulmonary 
circuit,  which  cannot  be  relieved  by  deep  inspiration.  In  other 
instances,  permanent  congestion  is  due  to  obstruction  of  the 
descending  vena  cava  by  a  thrombus,  or  more  frequently  by  the 
pressure  of  an  aneurism  or  other  tumor. 

LOCALIZED  TURGESCENCE,  that  is,  confined  to  a  single  vein 
and  its  branches,  is  always  the  result  of  a  thrombus  or  of  press- 
ure upon  the  blood-vessel. 

VENOUS  PULSATION. — Marked  pulsation  in  the  jugular  veins 
is  observed  when  there  is  permanent  engorgement  of  the  de- 
scending vena  cava,  which  generally  results  from  extreme 
emphysema  or  stenosis  of  the  mitral  valves. 

Pulsation  in  the  jugular  veins  is  most  frequently  observed 
just  above  the  clavicles,  though  sometimes  it  extends  over  the 
whole  course  of  the  vessel.  It  is  most  marked  in  the  dorsal 
decubitus ;  and  it  is  more  distinct  upon  the  right  than  upon 
the  left  side,  because  the  current  of  blood  from  the  right  ven- 
tricle, through  the  auricle,  finds  its  way  more  readily  into  the 
veins  of  that  side. 

Venous  pulsation  may  precede  the  impulse  of  the  apex  and 
the  first  sound  of  the  heart,  or  may  follow  it.  In  other 
words,  it  may  be  either  presystolic  or  systolic. 

Presystolic  venous  pulsation  is  due  to  regurgitation  of  blood 
into  the  veins  during  the  contraction  of  the  auricles. 

Systolic  venous  pulsation  is  due  to  contraction  of  the  right 
ventricle  with  regurgitation  of  blood  through  the  tricuspid 
valves  into  the  auricle  and  thence  into  the  veins.  When  slight 
and  temporary,  this  is  termed  relative  venous  pulsation  ;  when 
permanent,  it  is  known  as  absolute  venous  pulsation.  In  order 
to  be  of  value  in  the  diagnosis  of  tricuspid  regurgitation,  this 
pulsation  must  be  visible  during  both  inspiration  and  expira- 
tion. 

Pulsation  of  the  jugular  veins  may  be  simply  the  transmitted 
impulse  from  the  carotids.  In  such  cases,  there  will  be  simply 
a  lifting  impulse,  instead  of  expansion  of  the  blood-vessel,  and 
the  vein  will  not  be  tortuous  as  in  true  venous  pulsation. 

Pulsation  in  the  veins  on  the  back  of  the  hands  has  been 
repeatedly  noticed  by  Prof.  Peter,  of  Paris,  in  advanced  con 
sumption,  and  occasionally  in  other  affections.  The  pulsation 


2O6  THE  HEART  AND  AORTA. 

is  increased  by  compressing  the  wrist,  and  therefore  must  be 
propagated  through  the  capillaries  from  the  left  side  of  the 
heart.  It  may  be  seen  more  readily  than  it  can  be  felt. 

Prof.  Peter  thinks  this  phenomenon  due  to  paralysis  of  the 
muscular  fibres  of  the  arteries,  through  excess  of  carbonic  acid 
in  the  blood.  This  rare  phenomenon,  when  seen,  indicates  the 
near  approach  of  death. 

COLLAPSE  OF  THE  JUGULAR  VEINS  is  said  to  occur  with  the 
systole  of  the  ventricles,  in  some  cases,  where  there  is  aggluti- 
nation of  the  two  surfaces  of  the  pericardium. 

VENOUS  MURMURS. — The  venous  hum,  or  bruit  de  diable,  is  a 
constant  humming  sound,  which  is  frequently  obtained  over  the 
jugular  vein  just  above  the  clavicle,  or  in  the  interclavicular 
notch.  It  is  generally  associated  with  an  arterial  haemic  mur- 
mur. It  occasionally  occurs  in  healthy  persons,  but  is  most 
often  found  in  those  who  are  anaemic,  and  especially  in  chlorotic 
females. 

This  sign  is  usually  soft  and  humming  in  character,  but 
occasionally  it  is  musical,  hissing,  or  even  loud  and  roaring. 
It  is  most  likely  to  be  heard  when  the  patient  is  sitting  or 
standing. 

INTERMITTENT  VENOUS  MURMURS,  synchronous  with  the 
pulsations  of  the  heart,  are  among  the  rarest  signs  of  cardiac 
disease.  These  murmurs  may  be  presystolic,  systolic,  or  dias- 
tolic.  The  presystolic  murmurs  are  heard  only  when  the  pa- 
tient is  lying  down,  and  must  result  from  regurgitation  of  blood 
from  the  right  auricle  into  the  open  veins.  The  systolic  mur- 
mur is  usually  heard  most  distinctly  just  above  the  clavicle  on 
the  right  side.  It  is  due  to  regurgitation  from  the  right  ventri- 
cle through  the  auricle  and  into  the  veins.  The  diastolic  mur- 
mur is  extremely  rare.  It  is  said  to  require  for  its  production, 
hypertrophy  and  dilatation  of  the  heart,  with  aneurism.  These 
murmurs  may  be  mistaken  for  arterial  murmurs.  They  may 
be  distinguished  from  the  latter  by  slightly  pressing  on  the 
blood-vessel,  which  will  prevent  the  venous  hum,  but  will  not 
so  affect  the  arterial  murmur. 

THE  SPHYGMOGRAPH. 

By  the  use  of  the  sphygmograph  we  are  enabled  to  obtain  an 
accurate  graphic  statement  of  the  condition  of  the  circulatory 


THE   SPHYGMOGRAPH.  2O- 

system,  written,  so  to  speak,  by  the  heart  itself.  When  all  the 
conditions  are  favorable,  this  statement  furnishes  important 
information ;  but  so  much  depends  upon  the  adjustment  of  the 
instrument,  its  proper  working,  and  the  pressure  made  upon  the 


FIG.  30 — Marey's  Sphygmograph. 


artery,  that  up  to  the  present  time  the  instrument  has  been 
of  little  clinical  .value.  When  all  the  conditions  are  perfect,  the 
tracings  of  the  pulse  indicate :  the  time  occupied  by  the  systole 
and  the  diastole  of  the  heart ;  the  force  of  the  heart's  contrac- 


FlG.  31. — Normal  radial  pulse  (Foster). 

tion ;   the  resistance  to  the  onward  current  of  blood,  or  its 
regurgitation  through  the  valves,  and  the  tension  of  the  arteries. 
The  trace  is  composed  of  a  series  of  curves,  each  of  which 
represents  a  cardiac  pulsation. 


FlG.  32. — Normal  radial  pulse,  single  trace  enlarged. 

In  the  trace  of  the  normal  radial  pulse  as  shown  (Figs.  31 
and  32)  each  curve  consists  of  a  line  of  ascent,  a  summit,  and 


208 


THE  HEART  AND  AORTA. 


a  line  of  descent.  The  line  of  ascent  a  b  in  the  normal  condi- 
tion is  perpendicular  to  the  plane  of  the  base.  It  is  produced 
as  the  blood  is  propelled  into  the  artery.  This  line  indicates 
the  force  of  the  heart  by  its  height,  and  the  rapidity  of  the 
current  of  blood,  by  its  direction.  When  the  blood  is  retarded 


FIG.  33. — Aortic  obstruction  (Hayden). 

in  its  passage  from  the  left  ventricle  into  the  aorta,  as  in  con- 
striction at  the  aortic  orifice,  this  line  will  run  more  or  less 
obliquely  to  the  right,  according  to  the  amount  of  obstruction 
(Figs.  33  and  34).  When  the  pulsation  is  forcible  the  altitude 


FIG.  34. — Aortic  obstruction  (Foster). 

is  much  greater  than  when  it  is  weak.  The  summit  b  (Fig.  32) 
in  the  normal  condition  is  a  mere  point.  It  is  reached  at  the 
instant  when  the  artery  is  most  fully  distended,  immediately 
after  the  systole  of  the  left  ventricle.  When  the  artery  is  in- 


FlG.  35. — Mitral  regurgitation. 

completely  filled,  the  summit  is  rounded,  or  the  line  of  descent 
may  run  almost  horizontally  for  a  short  distance.  Examples 
of  this  are  found  in  mitral  regurgitation  (Fig.  35),  or  when  the 
artery  is  partially  occluded  by  an  aneurism  (Fig.  36),  and  when 


Right  arm. 


Left  arm. 
FIG.  36. — Aneurism  of  ascending  aorta  (Loomis). 

free  regurgitation  through  the  aortic  valves  prevents  full  dis- 
tention  of  the  artery  (Figs.  37  and  38).     The  line  of  descent  b  c 


THE  SPHYGMOGRAPH.  2og 

(Fig.  32)  corresponds  to  the  period  of  arterial  systole  and 
cardiac  diastole.  The  length  of  the  line  indicates  the  rapidity 
of  the  heart's  action.  When  the  heart  is  beating  rapidly,  the 
line  is  short,  and  when  beating  slowly,  it  is  correspondingly 
lengthened.  The  undulations  in  this  line  d  c  f  (Fig.  32)  are 


FIG.  37. — Aortic  regurgitation  (Boileau). 


FIG.  38. — Aortic  obstruction  and  regurgitation  (Loomis). 

known  as  the  first,  second,  and  third  secondary  waves.  The 
first  secondary  wave  d  is  produced  by  the  natural  contraction 
of  the  artery.  The  second  wave  e  corresponds  to  the  impulse 
occasionally  felt,  which  is  termed  dicrotism.  The  third  wave/ 
is  not  often  present.  The  depression  g  marks  the  complete 
closure  of  the  aortic  valves.  A  small  notch  in  the  line  of 
descent  is  often  seen  near  the  summit. 

Instead  of  having  the  form  shown  in  this  figure,  the  line  of 
descent  may  run  obliquely  downward  in  nearly  a  straight 
course.  It  may  have  a  generally  convex  or  concave  form,  and 
the  position  of  the  secondary  waves  may  vary  in  .distance  from 
the  points  b  and  c. 

Convexity  of  the  line  of  descent  or  small  secondary  waves 
(Fig.  39)  are  due  to  increased  arterial  tension,  as  when  there  is 
incipient  hypertrophy  of  the  heart  in  consequence  of  contrac- 
tion of  the  arterioles  in  Bright's  disease. 


FIG.  39. — Commencing  hypertrophy  from  obstruction  in  the  arterioles,  due  to 
Bright's  disease  of  the  kidneys. 

Concavity  of  the  line  of  descent  is  due  to  diminished  arterial 
tension. 

Sudden    dropping   of   the    line   of   descent   indicates  aortic 
regurgitation  (Figs.  37  and  43). 
14 


2IO 


THE  HEART  AND  AORTA. 


In  the  normal  trace,  the  first  secondary  wave  is  found  on  a 
level  with  the  junction  of  the  middle  with  the  upper  third  of 
the  line  of  ascent;  but  with  loss  of  elasticity  of  the  artery  it 
occurs  nearer  the  summit,  as  in  the  senile  pulse  (Fig.  40).  The 


FIG.  40. — Senile  pulse  (Foster). 

same  condition  of  the  artery  is  indicated  by  absence  of  dicro- 
tism. 


FIG.  41. — Mitral  constriction  (Hayden). 

In  mitral  stenosis  the  line  of  ascent  is  oblique,  the  summit 
rounded,  the  line  of  descent  prolonged,  and  the  secondary 
waves  are  absent  or  indistinct. 


FlG.  42  — Mitral  constriction  and  tricuspid  regurgitation  (Hayden). 

From  what  has  been  said,  we  learn  that  the  sphygmographic 
trace  is  not  diagnostic  of  any  disease,  as  will  be  at  once  appar- 
ent in  looking  over  the  tracings  taken  in  different  cases  of  the 
same  disease  (Figs.  33  and  34,  37  and  38);  but  the  general 
appearance  of  the  curve  may  indicate  special  conditions.  The 
special  points  to  notice  in  the  trace  are :  the  height  and  the 
obliquity  of  the  line  of  ascent ;  the  acuteness  or  rotundity  of 
the  summit ;  the  length  of  the  line  of  descent ;  the  convexity 
of  the  line  of  descent ;  and  the  nearness  to  the  summit  of  the 
secondary  waves. 


FlG.  43 — Hypertrophy  and  dilatation  of  the  heart  (Hayden).     High  line  of  ascent  ; 
sudden  falling  of  line  of  descent. 

Dr.  Sanderson  considered  this  instrument  principally  useful 


THE    SPHYMOGRAPH.  211 

in  detecting  increased  arterial  tension,  consequent  upon  hyper- 
trophy of  the  left  ventricle  (Fig.  39). 

The  late  Dr.  Anstie  thought  that  when  the  instrument  worked 
perfectly,  if  accurately  adjusted,  it  would  be  of  value  in  the 
diagnosis,  not  only  of  commencing  hypertrophy  of  the  heart, 
but  also  of  aortic  regurgitation  (Fig.  37),  and  especially  of 
aneurism  of  the  aorta  (Fig.  36). 


LECTURE   XX. 

DIAGNOSIS  AND   TREATMENT   OF   CARDIAC 
DISEASES. 

PERICARDITIS. 

Pericarditis  is  an  inflammation  of  the  serous  membrane 
enveloping  the  heart.  It  results  generally  from  rheumatism, 
renal  disease,  or  pyaemia.  Inflammation  here,  as  in  other 
serous  membranes,  first  causes  dryness,  which  is  soon  followed 
by  an  exudation  of  inflammatory  lymph,  and  this  is  succeeded 
or  accompanied  by  an  effusion  of  serum.  This  disease  may  be 
divided  into  three  stages,  similar  to  the  three  stages  of  pleurisy, 
viz. :  the  first,  or  dry  stage ;  the  second,  or  stage  of  effusion ; 
and  the  third,  or  stage  of  absorption. 

SYMPTOMS. 

The  most  common  symptoms  are  pain  in  the  prsecordial  and 
epigastric  regions,  shooting  to  the  shoulder,  and  augmented  by 
movements  or  by  pressure ;  with  more  or  less  fever,  a  small 
wiry,  irregular  pulse,  cedema,  dyspnrea,  and  occasionally  dys- 
phagia.  Any  or  all  of  these  symptoms  may  be  absent. 

SIGNS. 

The  essential  signs  in  the  order  of  their  occurrence  are  : 
irritable  action  of  the  heart ;  friction  fremitus  and  murmur ; 
increased  dulness  over  the  heart,  ultimately  obtained  over  a 
triangular  area,  which  extends  considerably  to  the  left  of  the 
apex  ;  with  feebleness  of  the  heart's  impulse  and  sounds,  both  of 
which  are  intensified  by  causing  the  patient  to  lean  well  forward. 

Signs  of  the  First  Stage. 

INSPECTION  AND  PALPATION. — In  the  first  stage,  upon  inspec- 
tion and  palpation,  we  discover  nothing  except  an  irritable 
action  of  the  heart,  with  slightly  increased  force,  and  in  the 
latter  part  of  the  first  stage,  friction  fremitus. 


PERICARDITIS. 

AUSCULTATION.— Upon  auscultation  a  grazing  friction  sound 
may  sometimes  be  heard,  very  early  in  the  disease,  along  the 
left  border  of  the  sternum.  This  sound  may  be  distinguished 
from  endocardial  murmurs  by  its  rhythm  and  seat,  and  by  the 
fact  that  its  intensity  is  increased  by  pressure.  In  the  latter 
part  of  this  stage,  friction  sounds  of  a  harsher  quality  may  be 
obtained.  These  may  be  either  feeble  or  very  intense. 

Signs  of  the  Second  Stage. 

In  the  second  stage  of  the  disease,  the  signs  vary  somewhat 
in  proportion  to  the  amount  of  the  effusion. 

INSPECTION. — In  children  or  in  young  adults,  with  elastic 
chest-walls,  bulging  of  the  prsecordial  region  extending  from 
the  second  to  the  sixth  rib,  may  be  noticed.  The  respiratory 
movements  of  the  left  lung  are  somewhat  disturbed,  and  the 
position  of  the  apex-beat  is  altered,  being  carried  upward  and 
to  the  left  into  the  fourth  intercostal  space. 

PALPATION  confirms  the  signs  obtained  by  inspection.  The 
impulse  of  the  heart  is  feeble,  especially  when  the  patient  is 
lying  upon  his  back ;  but  when  he  is  leaning  forward  it  is  much 
more  forcible  than  in  either  the  erect  or  the  recumbent  posi- 
tion. This  is  an  important  fact  in  the  diagnosis.  When  the 
pericardium  is  greatly  distended,  the  diaphragm  may  be  forced 
downward,  so  as  to  cause  bulging  in  the  epigastric  region. 
Undulation  of  the  whole  prsecordial  region,  due  to  the  action 
of  the  heart  upon  the  fluid  inclosing  it,  may  frequently  be  felt, 
and  occasionally  fluctuation  can  be  detected. 

PERCUSSION. — Upon  percussion  both  the  superficial  and  the 
deep-seated  areas  of  dulness  are  found  to  be  increased.  At  first 
the  area  of  deep-seated  dulness  is  increased  in  its  vertical  diam- 
eter, and  dulness  is  noticeable  principally  above  the  base  of 
the  heart  in  the  second  intercostal  space,  where  the  serum  first 
collects.  This  is  especially  noticeable  when  the  person  is  in  the 
recumbent  posture.  When  the  effusion  becomes  somewhat 
greater,  serum  collects  at  the  lower  part  of  the  pericardial  sac ; 
dulness  is  then  increased  in  the  transverse  diameter  at  the  level 
of  the  apex,  and  the  area  of  dulness  becomes  triangular  with 
its  base  downward,  corresponding  to  the  form  of  the  pericar- 
dium. This  triangular  shape  remains,  however  great  the  effu- 
sion may  be.  In  extensive  effusion,  the  dulness  may  extend 


214 


THE  HEART  AND  AORTA. 


from  the  first  rib  above  to  the  resonance  of  the  stomach  below, 
and  laterally  from  the  right  nipple  to  a  point  about  two  inches 
beyond  the  left  nipple.  The  position  of  the  apex-beat  having 
been  determined  by  palpation  or  by  auscultation,  the  existence 
of  dulness  to  the  left  of  this  point  and  below  it  becomes  an 
important  element  in  distinguishing  pericarditis  from  enlarge- 
ment of  the  heart ;  in  the  latter  the  apex-beat  corresponds  very 
nearly  to  the  limit  of  dulness  on  the  left. 

In  the  differential  diagnosis  of  pericardial  effusions,  Dr.  T.  M.  Rotch,  of  Boston, 
considers  an  area  of  flatness  in  the  fifth  intercostal  space  of  the  right  side,  about  an  inch 
from  the  border  of  the  sternum,  a  very  important  sign. 

AUSCULTATION. — The  friction  sounds  which  are  usually 
heard  in  the  first  stage  generally  disappear  when  effusion 
occurs,  in  consequence  of  the  separation  of  the  pericardial  sur- 
faces ;  yet  they  often  remain  at  the  base  of  the  heart  through- 
out the  entire  course  of  the^  disease.  In  the  second  stage,  the 
heart-sounds  are  feeble  and  distant,  but  they  may  be  rendered 
more  distinct  by  causing  the  patient  to  lean  well  forward ; 
sometimes. friction  sounds  may  be  reproduced  by  this  means. 

Pulmonary  sounds  are  not  heard  over  the  area  of  flatness  in 
the  prsecordial  region. 

Signs  of  the   Third  Stage. 

In  the  third  stage  of  the  disease,  the  signs  of  the  second  stage 
disappear,  the  bulging  gradually  diminishes,  the  apex-beat 
becomes  more  and  more  perceptible,  and  returns  to  its  normal 
position  ;  there  is  a  gradual  diminution  in  the  area  of  dulness  : 
the  friction  sounds  may  return  and  remain  until  resolution 
has  taken  place,  or  until  the  two  surfaces  of  the  pericardium 
have  become  adherent ;  and  the  respiratory  sounds  may  again 
be  heard  in  the  prascordia. 

Exceptional. — Occasionally  friction  sounds  continue  a  long  time  after  apparent 
recovery. 

We  have  no  means  of  determining  when  adhesions  of  the 
pericardial  surface  have  taken  place  unless  the  external  layer 
of  the  sac  has  also  adhered  to  the  chest-walls.  When  this 
accident  has  occurred,  the  intercostal  spaces  are  seen  to  be 
depressed  with  each  systole  of  the  ventricles,  and  ultimately 
permanent  depression  of  the  prsecordial  region  may  take  place. 


TREATMENT   OF   PERICARDITIS.  21 5 

In  some  cases,  when  the  heart  is  considerably  hypertrophied 
and  dilated,  dragging-in  of  the  epigastric  region  is  caused  by 
each  pulsation  of  the  heart. 

DIFFERENTIAL    DIAGNOSIS. 

Pericarditis  is  liable  to  be  mistaken  for  pleurisy,  or  endo- 
carditis. 

Pleurisy. — The  first  stage  of  this  affection  causes  pain  and 
friction  sounds  similar  to  those  of  pericarditis  and  if  it  happen 
to  involve  only  the  anterior  portion  of  the  left  pleura,  consider- 
able care  will  be  necessary  to  avoid  an  error  in  diagnosis.  The 
distinctive  features  between  the  two  affections  are  presented  in 
the  following  table : 

PERICARDITIS.  PLEURISY. 

Symptoms. 
Pain  usually  in  the  prpecordial  region.  Pain  usually  in  the  infra-axillary  region. 

Signs. 

Friction  sounds  confined  to  the  region  Friction  sounds,  though  they  may  be 

of  the  heart  and  synchronous  with  its  confined  to  the  pracordial  region,  are 
movements,  and  not  affected  by  the  respi-  generally  heard  farther  to  the  left.  They 
ratory  movements.  are  not  synchronous  with  the  pulsations 

of  the  heart,  but  occur  with  the  respira- 
tory movements,  and  almost  invariably 
cease  when  respiration  is  suspended. 

Endocarditis. — For  the  distinctive  features  between  this  dis- 
ease and  inflammation  of  the  pericardium  see  page  218. 

TREATMENT. 

With  the  first  symptoms  of  pericarditis,  the  patient  should  be 
placed  in  bed,  there  to  remain  absolutely  quiet  until  convales- 
cence has  been  established.  Hot  poultices  should  be  kept  con- 
stantly applied  to  the  whole  anterior  surface  of  the  chest. 
Opiates  should  be  given  in  just  sufficient  quantity  to  control 
pain.  Depressing  measures  of  all  kinds  must  be  avoided. 

If  the  cause  of  the  disease  can  be  ascertained,  it  should  be 
removed.     When  this  is  not  possible,  its  effects  should  be  moc 
fied  by  proper  treatment.     Rheumatism  will  call  for  alkalies, 
guaiacum,  and  small  doses  of  colchicum.     The  latter  must  not 
be  given  in  doses  sufficient  to  derange  the  digestive  organs  or 
to  cause  depression.     Salicylic  acid  should  not  be  given  < 
account  of  its  depressing  effects  on  the  heart.     If  this  affection 


2I6  THE  HEART  AND  AORTA. 

follows  depressing  fevers,  the  supporting  measures  which  are 
required  for  the  latter  should  be  more  assiduously  applied.  If 
it  results  from  Bright's  disease,  saline  cathartics  in  moderate 
doses;  diaphoretics,  especially  vapor  or  hot-air  baths;  dry 
cupping  over  the  loins;  and  small  doses  of  digitalis  will  be 
indicated.  In  most  cases,  iron  is  a  necessary  remedy,  and 
quinia  will  usually  be  beneficial  in  maintaining  the  patient's 
strength. 

The  diet  should  be  concentrated  and  nutritious,  and,  so  far  as 
possible,  fluids  should  be  avoided.  If  effusion  takes  place,  its 
removal  will  be  favored  more  by  the  means  calculated  to  main- 
tain the  strength  than  by  the  various  drastic  cathartics  so  often 
prescribed.  In  many  cases,  good  effects  will  follow  the  judi- 
cious use  of  hot-air  baths,  to  promote  diaphoresis ;  of  iodide, 
bitartrate,  or  acetate  of  potassium,  or  fluid  extract  of  scoparius, 
to  cause  diuresis ;  or  fluid  extract  of  euonymus  or  small  doses 
of  elaterium,  to  induce  catharsis. 

If  pressure  on  the  heart  from  pericardial  effusion  becomes 
excessive,  the  question  of  aspiration  will  suggest  itself.  With 
reference  to  this  operation  1  would  recommend  it  in  cases 
where  heart-failure  seems  imminent,  but  it  should  be  held  as  a 
dernier  resort. 

During  convalescence  from  this  disease,  the  greatest  care 
should  be  exercised  for  ten  or  twelve  weeks  to  avoid  exposure 
or  active  exercise.  The  heart  is  always  weakened  by  such  an 
attack,  and  there  is  a  tendency  to  dilatation,  which  should  be 
guarded  against  by  small  doses  of  digitalis,  strychnia,  and 
arsenic.  To  promote  the  patient's  strength  still  farther,  we 
should  make  free  use  of  iron  and  good  diet.  The  patient  should 
avoid  everything  which  would  cause  the  organ  extra  labor. 


CHRONIC  PERICARDITIS. 

If  acute  inflammation  of  the  pericardium  does  not  terminate 
in  recovery  within  three  weeks,  the  disease  is  termed  chronic 
pericarditis.  This  condition  may  be  characterized  by  a  collec- 
tion of  fluid  in  the  pericardium  or  by  adhesion  of  the  two  sur- 
faces of  this  sac. 

In  the  former  case,  counter-irritation,  diuretics,  and  cathartics 


ENDOCARDITIS.  217 

are  indicated  ;  but  in  both  cases  iron  and  cardiac  tonics  must 
be  constantly  employed  and  excessive  action  must  be  avoided. 


PNEUMO-HYDROPERICARDIUM. 

This  is  one  of  the  rarest  of  cardiac  diseases.  As  indicated 
by  the  name,  it  is  a  condition  in  which  air,  or  gas,  and  fluid 
occupy  the  pericardial  sac.  The  essential  signs  of  the  affection 
are  tympanitic  resonance  over  the  air,  and  flatness  over  the 
fluid ;  and  on  auscultation  a  splashing  sound  synchronous  with 
the  pulsation  of  the  heart  and  entirely  independent  of  the 
respiratory  movements. 

DIFFERENTIAL  DIAGNOSIS. 

Pneumo-hydrothorax  and  certain  conditions  of  the  stomach 
might  possibly  be  mistaken  for  this  affection ;  but  there  is  no 
danger  of  an  error  in  diagnosis  if  we  remember  that  the  signs 
of  pneumo-hydrothorax  are  found  on  the  side  and  posteriorly  ; 
and  that  the  splashing  sounds  which  are  sometimes  produced 
within  the  stomach  are  heard  below  the  prascordial  region. 

TREATMENT. 

These  cases  are  usually  speedily  fatal,  and  when  of  longer 
duration  the  treatment  must  be  expectant. 

ENDOCARDITIS. 

This  is  an  inflammation  of  the  lining  membrane  of  the  heart. 
It  seldom  occurs  as  a  primary  disease.  It  is  frequently  asso- 
ciated with  pericarditis,  and  it  is  often  the  result  of  pyaemia, 
Bright's  disease,  or  acute  rheumatism. 

SYMPTOMS. 

The  usual  symptoms  of  this  affection  are :  a  sense  of  uneasi- 
ness about  the  heart,  fever,  a  short  cough,  dyspnoea,  and  an 

anxious  countenance. 

SIGNS. 

The  affection  is  often  denoted  by  a  feeble  ventricular  murmur, 
apparently  due  to  thickening  of  the  valves,  with  possibly  short- 
ening of  the  chordae  tendinas. 

When  the  symptoms  just  mentioned  come  on  in  the  course 
of  any  of  the  affections  named,  especially  if  a  ventricular  mur- 


2Ig  THE  HEART  AND  AORTA. 

mur  supervenes  over  a  heart  the  sounds  of  which  were  formerly 
normal,  we  may  reasonably  conclude  that  inflammation  of  the 
endocardium  exists. 

DIFFERENTIAL    DIAGNOSIS. 

Endocarditis,  when  occurring  independently  of  pericarditis, 
is  liable  to  be  mistaken  for  the  latter  disease.  Pericarditis  may 
be  distinguished  from  uncomplicated  inflammation  of  the  endo- 
cardium by  the  rhythm  and  seat  of  the  murmur. 

ENDOCARDITIS.  PERICARDITIS. 

Rhythm  of  murmur. 

Murmur  synchronous    with    the   first  Murmur  not  exactly  synchronous  with 

sound  of  the  heart,  and  does  not  occur         the  valvular  sounds,  and  often  occurs  dur- 
with   the    diastole    unless    regurgitation         ing  both  the  systole  and  diastole  of  the 
takes  place  through  the  aortic  or  pulmo-         heart, 
nary  semilunar  valves. 

Seat  of  murmur. 

Murmur  loudest  at  apex  of  heart.  Murmur  heard   loudest    at   border   of 

sternum  near  the  fifth  left  costal  cartilage. 

TREATMENT. 

This  affection  is  nearly  always  the  result  of  rheumatism, 
chorea,  pyaemia,  or  the  acute  exanthematous  fevers.  The 
proper  treatment  for  these  affections  is  that  which  should  in 
the  main  be  employed  in  the  secondary  heart  disease. 

In  this  disease,  perfect  quiet  should  be  maintained,  not  only 
during  the  active  stage,  but  also  during  the  convalescence. 

In  the  very  inception  of  the  attack,  a  full  dose  of  quinine  will 
occasionally  cut  it  short.  Later  in  the  disease,  this  remedy 
and  iron  are  very  useful.  During  the  treatment,  the  patient 
should  be  kept  in  a  warm  room  at  70°  to  75°  F.,  and  the  chest 
should  be  specially  guarded  from  exposure. 
.  Sibson  recommends  a  liniment  of  belladonna  and  chloroform 
sprinkled  on  cotton  wool  and  kept  applied  to  the  praecordial 
region.  Great  depression  calls  for  alcoholic  stimulants  and 
digitalis.  The  latter  in  moderate  doses,  combined  with  quinine, 
arsenic,  and  iron,  is  needed  during  convalescence,  but  care 
should  be  taken  not  to  overstimulate  the  heart. 

Exceptional. — Nearly  all  cases  of  endocarditis  are  associated  with,  or  follow  other 
diseases,  and  are  attended  by  symptoms  which  demand  supporting  treatment ;  but  now 
and  then  one  occurs  without  apparent  cause  in  a  robust  person  of  full  habit.  In  such 
case  general  bleeding  would  undoubtedly  prove  beneficial  by  relieving  the  over- 
burdened heart. 


HYPERTROPHY   OF   THE    HEART.  21Q 


HYPERTROPHY  OF  THE  HEART. 

Synonyms. — Enlargement  of  the  heart;  Active  aneurism; 
Hypersarcosis  cordis. 

This  consists  of  hypertrophy  of  the  muscular  walls  of  one 
or  more  of  the  cardiac  cavities  without  enlargement  of  the 
cavity  itself.  It  is  due  to  increased  functional  activity  of  the 
heart,  brought  about  in  some  cases  by  obstruction  to  the  cir- 
culation at  one  of  the  valvular  orifices,  as  by  contraction  of  the 
valves ;  and  in  some  by  obstruction  in  the  pulmonary  circuit, 
due  to  emphysema  or  other  pulmonary  disease.  In  other  cases 
the  obstruction  occurs  in  the  arterioles,  in  consequence  of  their 
contraction  caused  by  retention  in  the  blood  of  morbific  mate- 
rial, as  for  example  in  Bright's  disease,  where  proper  elimina- 
tion of  urea  does  not  take  place. 

SYMPTOMS. 

The  symptoms  are  not  marked. 

SIGNS. 

The  signs  in  this  affection  vary  with  the  extent  of  the  hyper- 
trophy, and  with  the  portion  of  the  organ  involved.  The  essen- 
tial signs  are :  increased  area  of  dulness  and  increased  force 
of  impulse  while  the  heart's  action  remains  regular. 

INSPECTION. — In  children,  there  is  frequently  a  prominence 
of  the  prascordial  region  when  the  hypertrophy  is  general,  but 
in  adults  this  cannot  be  detected.  The  action  of  the  heart  is 
regular  and  forcible.  If  the  left  ventricle  alone  be  hyper- 
trophied,  the  apex-beat  will  be  seen  farther  than  usual  to  the 
left,  and  the  visible  area  of  the  impulse  will  be  increased.  »If 
the  right  ventricle  is  affected,  there  will  be  strong  epigastric 
pulsation,  and  the  apex-beat,  if  perceptible,  will  be  below  the 
usual  position  and  to  the  right  of  it. 

PALPATION  confirms  the  signs  as  to  the  position  and  force  of 
the  apex-beat. 

PERCUSSION. — On  percussion  there  is  an  increase  in  the  areas 
of  superficial  and  deep-seated  cardiac  dulness.  -The  deep- 
seated  dulness  in  simple  hypertrophy  of  the  left  ventricle 
seldom  extends  more  than  an  inch  to  the  left  of  the  normal 
position.  A  larger  area  is  almost  always  associated  with  more 


22Q  THE  HEART  AND  AORTA. 

or  less  dilatation.  In  hypertrophy  of  the  right  ventricle,  the 
dulness  extends  considerably  to  the  right  of  the  sternum. 

AUSCULTATION. — In  hypertrophy  of  the  ventricles,  the  first 
sound  of  the  heart  is  greatly  increased  in  intensity,  and  the 
elements  of  muscular  contraction  and  impulsion  are  especially 
marked.  The  second  sound  is  also  increased  in  intensity  and 
is  more  widely  diffused  than  normal.  The  heart's  action 
remains  regular  as  long  as  the  hypertrophy  compensates  for 
the  obstruction. 

The  respiratory  murmur  is  diminished  or  is  absent  over  a 
portion  of  the  prsecordial  region  corresponding  to  the  displace- 
ment of  the  lung. 

TREATMENT. 

Hypertrophy  of  the  heart  is  nearly  always  a  conservative 
process,  and  should  be  favored  rather  than  retarded ;  but  in 
some  instances,  symptoms  appear  of  cerebral  congestion,  such 
as  pain,  fulness  of  the  head  and  vertigo,  and  require  prompt 
attention.  Bleeding  will  temporarily  relieve  these,  but  it  is  not 
to  be  recommended.  Tincture  of  aconite  root  in  doses  of  two 
or  three  drops  every  two  hours  until  relief  is  obtained  is  the 
most  efficient  remedy  in  such  instances.  It  must  not  be  for- 
gotten that  similar  symptoms  are  caused  by  passive  congestion 
depending  upon  cardiac  failure,  and  that  in  such  cases  the 
aconite  would  be  harmful.  These  latter  cases  I  have  found 
most  quickly  relieved  by  nux  vomica.  The  causes  of  the 
hypertrophy  should  be  sought  for  and  so  far  as  possible  they 
should  be  removed. 


HYPERTROPHY  AND  DILATATION  OF  THE  HEART. 

This  consists  of  hypertrophy  of  the  muscular  walls  with  dila- 
tation of  the  cavities.  It  is  caused  by  yielding  of  the  walls 
to  excessive  pressure,  which  may  result  from  the  same  causes 
which  induced  the  hypertrophy  ;  or  from  regurgitation  of 
blood  through  incompetent  valves. 

SYMPTOMS. 

Dyspnoea  on  exertion,  oedema  especially  of  the  ankles,  and 
occasional  vertigo  and  palpitation  of  the  heart,  are  common 
symptoms.  In  this  affection,  the  action  of  the  heart  remains 


HYPERTROPHY  OF   THE   HEART.  221 

regular  if  the  hypertrophy  is  sufficient  to  compensate  for  the 
dilatation  ;  but  it  becomes  irregular  if  the  dilatation  predomi- 
nates. 

SIGNS. 

The  essential  signs  are:  increased  area  of  visible  impulse, 
with  displacement  of  the  apex-beat  downward  and  to  the  left, 
and  a  peculiar  heaving  impulse  with  increased  area  of  dulness. 
Endocardial  murmurs  are  nearly  always  present. 

INSPECTION  AND  PALPATION — The  area  over  which  the 
cardiac  impulse  may  be  seen  and  felt  is  greatly  increased. 
Sometimes  it  may  be  seen  over  the  entire  left  side,  and  the 
impulse  often  has  a  peculiar  heaving  or  lifting  character,  which 
is  sufficient  in  some  instances  to  shake  the  bed  on  which  the 
patient  is  lying.  The  apex-beat  may  sometimes  be  found  two 
or  three  inches  to  the  left  of  the  left  nipple,  and  as  low  as  the 
eighth  rib. 

PERCUSSION. — The  area  of  dulness  is  increased  to  the  left  and 
downward,  in  proportion  to  the  enlargement  of  the  organ ;  or, 
if  the  right  ventricle  is  affected,  it  is  also  increased  to  the  right. 

AUSCULTATION. — Both  sounds  of  the  heart  are  prolonged, 
and  they  may  often  be  heard  over  the  entire  chest.  If  valvular 
murmurs  are  present,  they  will  be  loudest  in  the  normal  areas, 
which  were  described  in  a  previous  lecture  (Fig.  27,  page  192) ; 
but  they  may  also  be  heard  in  some  instances  over  the  whole 
thorax. 

DIFFERENTIAL  DIAGNOSIS. 

This  affection  might  be  mistaken  for  pericarditis,  hyper- 
trophy of  the  ventricles,  or  for  simple  dilatation  of  the  heart. 

It  may  be  distinguished  from  pericarditis  or  from  dilatation  of 
the  heart  by  the  force  of  the  apex-beat  and  by  the  intensity  of 
the  heart  sounds.  It  can  easily  be  distinguished  from  simple 
hypertrophy  of  the  heart  by  the  size  of  the  area  of  dulness  and 
the  force  and  character  of  the  impulse. 

TREATMENT. 

The  treatment  of  this  condition  is  essentially  the  same  as 
that  of  valvular  disease  of  the  heart,  with  which  it  is  nearly 
always  associated  (page  232). 


222  THE  HEART  AND  AORTA. 


DILATATION   OF  THE   HEART. 

Synonyms. — Aneurism  or  passive  aneurism  of  the  heart ;  Car- 
diectasis. 

This  consists  of  dilatation  of  the  cavities  of  the  heart  without 
thickening  of  their  muscular  walls.  It  results  from  excessive 
pressure,  which  is  not  compensated  for  by  hypertrophy,  and 
which  follows  as  a  consequence  of  valvular  disease  of  the  heart, 
of  obstruction  to  the  pulmonary  circuit  through  emphysema, 
or  of  cirrhosis  of  the  lungs. 

Dilatation  is  also  produced  by  weakening  of  the  muscular 
fibres,  as  in  anaemia,  fevers,  and  obesity. 

SYMPTOMS. 

The  most  frequent  symptoms  are :  rapid  irregular  pulse ; 
palpitation  of  the  heart ;  syncope  ;  dyspnoea  ;  oedema ;  turges- 
cence  of  the  veins,  and  congestion  of  the  various  organs,  causing 
oedema  of  lungs,  jaundice,  or  albuminuria. 

SIGNS. 

The  most  important  signs  of  this  disease  are :  feeble  and 
irregular  action  of  the  heart ;  an  enlarged  area  of  dulness,  oval 
in  form,  and  not  extending  far  to  the  left  of  the  apex-beat ;  and 
feebleness  of  the  heart-sounds. 

INSPECTION. — The  impulse  of  the  heart's  apex  may  not  be 
visible.  If  seen  at  all,  it  is  likely  to  extend  over  a  wider 
area  than  in  health,  and  the  point  of  maximum  intensity  is  not 
easily  determined.  It  is  occasionally  of  an  undulatory  char- 
acter. 

PALPATION. — The  apex-beat  is  found  below  the  normal  posi- 
tion and  to  the  left  of  it,  and  the  heart's  action  is  irregular  in 
rhythm.  The  impulse  is  feeble,  and  this  characteristic  enables 
us  readily  to  distinguish  this  affection  from  hypertrophy,  or 
hypertrophy  with  dilatation.  A  purring  tremor  may  fre- 
quently be  obtained,  especially  when  there  is  mitral  regurgita- 
tion. 

PERCUSSION. — The  area  of  cardiac  dulness  is  increased  to 
the  right  when  the  right  cavities  are  involved,  and  to  the  left 


DILATATION   OF   THE   HEART.  223 

when  the  left  cavities  are  dilated.  This  area  maintains  an  oval 
outline,  which  enables  us  to  distinguish  the  disease  from  peri- 
carditis, in  which  the  signs,  upon  inspection  and  palpation,  are 
nearly  identical. 

AUSCULTATION. — Both  sounds  of  the  heart  are  short,  abrupt, 
and  feeble.  They  are  often  of  equal  length.  The  second  sound 
may  be  inaudible  at  the  apex. 

If  valvular  murmurs  have  been  present,  these  become  less 
intense,  and  sometimes  of  a  swirling  character.  The  respi- 
ratory sounds  over  the  upper  portion  of  the  left  lung  are  often 
enfeebled. 

DIFFERENTIAL   DIAGNOSIS. 

There  is  no  difficulty  in  distinguishing  this  affection  from  all 
other  diseases  excepting  pericarditis.  The  distinctive  features 
between  these  two  are  shown  below. 

DILATATION  OF  THE  HEART.  PERICARDITIS. 

t  History. 

Chronic.  Acute.  i 

Palpation. 

Impulse  feeble  and  irregular — felt  be-  Impulse  feeble  and  irregular — felt  above 

low  and  to  the  left  of  its  normal  position,         its  normal  position,  and  increased  in  force 
and  not  materially  affected  by  leaning  the         when  the  patient  leans  forward, 
patient's  body  forward. 

Percussion. 

Oval  outline  of  dulness  which  does  not  Triangular  outline  of  dulness  which 

extend  far  to  the  left  of  the  apex.  extends  considerably  to  the  left  of  the 

apex-beat. 

Auscultation. 

Heart-sounds  feeble,  short,  and  valvu-  Heart-sounds  feeble,  and  not  so  mark- 

lar,  and  not  altered  by  position.  edly  valvular,  but  intensified  by  leaning 

the  body  forward. 

ASYSTOLISM. 

This  is  a  term  which  has  been  applied  to  a  condition  in 
which  the  ventricle  cannot  completely  empty  itself.  It  is 
nearly  always  associated  with  dilatation  of  the  right  ventricle. 

In  this  condition,  the  impulse  of  the  heart  becomes  very 
feeble,  and  shortly  before  death  the  valvular  sounds  or  mur 
murs  which  may  have  been  present  become  almost  inaudible, 
or  they  may  be  supplanted  by  a  continuous  humming  sound. 


224  THE   HEART   AND 

Tricuspid  regurgitation  with  pulsation  in  the  jugular  veins  is 
likely  to  be  developed  during  the  course  of  this  affection. 

TREATMENT. 

The  treatment  of  dilatation  of  the  heart  and  of  asystolism 
should  be  the  same  as  that  recommended  for  valvular  disease 
of  the  heart,  page  232. 


•LECTURE  XXL 

DIAGNOSIS    AND    TREATMENT    OF    CARDIAC 
DISEASES— Continued. 

ATROPHY  OF  THE  HEART. 

Synonym. — Phthisis  of  the  heart. 

This  is  an  extremely  rare  affection.  It  consists  of  simple 
attenuation  of  the  walls  of  the  heart,  the  cavities  usually 
remaining  of  normal  size,  but  in  some  cases  both  the  thickness 
of  the  walls  and  the  size  of  the  cavities  are  diminished. 

The  affection  is  sometimes  congenital.  It  may  be  caused  by 
chronic  wasting  disease  or  by  constriction  of  the  coronary 
arteries. 

DIAGNOSIS. 

A  diagnosis  can  rarely,  if  ever,  be  made  during  life ;  but  in 
the  congenital  variety  we  may  possibly  detect  decreased  area 
of  cardiac  dulness  independent  of  pulmonary  emphysema. 

FATTY  DEGENERATION  OF  THE  HEART. 

There  are  two  recognized  varieties  of  this  disease :  one,  in 
which  there  is  a  deposit  of  fatty  tissue  upon  the  surface  of  the 
heart  or  between  its  muscular  fibres ;  and  the  other,  in  which 
the  muscular  fibres  themselves  undergo  fatty  degeneration. 
The  first  variety  is  attributed,  by  Kennedy,  to  a  "  fatty  diathe- 
sis ; "  the  second  variety  usually  results  from  atheromatous 
degeneration  of  the  aorta,  old  age,  alcoholism,  gout,  or  some 
prolonged  wasting  disease.  The  physical  signs  of  either  are 
not  always  well  marked,  and  a  positive  diagnosis  is  often 
impossible. 

SYMPTOMS. 

The  symptoms  of  fatty  disease  of  the  heart  are  practically 
the  same  in  both  varieties,  and  they  are  of  the  greatest  impor- 
tance in  a  diagnostic  point  of  view.  The  most  prominent  of 


THE   HEART   AND   AORTA. 

these  are :  melancholia  or  irritability  of  temper ;  partial  loss  of 
memory,  or  hesitating  speech ;  palpitation  of  the  heart ;  dys- 
pncea  and  angina  pectoris.  Other  symptoms,  which  are  fre- 
quently noticed,  are :  pallor  and  a  sallow  appearance  of  the 
sdtrface,  with  congestion  of  the  ears  and  lips ;  weight  and  pain 
in  the  head  ;  a  sense  of  pain  in  the  epigastrium  ;  double  vision 
or  loss  of  vision  ;  and  the  arcus  senilis.  Two  other  symptoms 
sometimes  occur,  and  when  found,  they  are  of  the  greatest 
value  in  a  diagnostic  point  of  view.  These  are  pseudo-apo- 
plexy and  the  Cheyne-Stokes  respiration. 

Pseudo-apoplexy  consists  of  sudden  attacks,  similar  to  those 
of  apoplexy,  in  which  the  individual  suddenly  loses  conscious- 
ness and  falls.  It  differs  from  true  apoplexy  in  the  rapidity  of 
recovery.  When  these  attacks  first  make  their  appearance, 
they  seldom  continue  more  than  a  minute  or  two,  and  the 
patient  comes  out  of  them  feeling  perfectly  well ;  but,  as  the 
disease  progresses,  they  become  more  and  more  frequent,  pro- 
longed, and  severe,  and  are  attended  with  paralysis ;  but  even 
then  the  patient  usually  recovers  completely  in  a  few  days  at 
most. 

The  "  Cheyne-Stokes  respiration  "  appears  late  in  the  disease. 
"  It  consists  in  the  occurrence  of  a  series  of  inspirations  increas- 
ing to  a  maximum,  and  then  declining  in  force  and  length  until 
a  state  of  apparent  apncea  is  established.  In  this  condition  a 
patient  may  remain  for  such  a  length  of  time  as  to  make  his 
attendants  believe  he  is  dead,  when  a  low  inspiration,  followed 
by  one  more  decided,  marks  the  commencement  of  a  new 
ascending  and  descending  series  of  inspirations."  Although 
an  important  symptom  of  fatty  heart,  it  must  not  be  forgotten 
that  this  peculiar  respiration  occurs  in  dilatation  or  valvular 
disease  of  the  organ. 

In  the  variety  of  this  disease  which  is  caused  by  deposit, 
obesity  is  a  symptom  of  great  importance.  In  fatty  degenera- 
tion of  the  muscular  fibres,  loss  of  weight,  after  a  person  has 
been  fleshy,  is  a  valuable  symptom. 

SIGNS. 

In  fatty  deposit  on  the  heart,  the  pulse  is  usually  slow — forty 
or  fifty  per  minute — full,  and  sometimes  even  bounding.  Very 
careful  percussion  may  detect  an  increase  in  the  area  of  cardiac 
dulness. 


FATTY  DEGENERATION  OF  THE  HEART.        227 

In  fatty  degeneration  of  the  muscular  fibres,  auscultation  over 
the  apex  will  sometimes  reveal  slow  pulsation  ;  and  even  when 
the  pulsation  equals  seventy  per  minute,  it  often  conveys  to 
the  ear  a  sense  of  slowness. 

The  impulse  of  the  apex  is  weak,  and  the  intensity  of  the 
sounds  feeble  in  either  variety.  If  valvular  disease  co-exists,  a 
soft  systolic  souffle  may  be  detected  by  care. 

INSPECTION  AND  PALPATION.— The  impulse  is  either  indis- 
tinct or  absent ;  the  apex  remains  in  its  normal  position ;  the 
action  of  the  heart  is  often  irregular,  frequently  intermittent, 
and  may  be  either  slow  or  rapid.  The  pulse  in  fatty  deposit  is 
slow  and  full ;  in  fatty  degeneration  it  may  be  slow  or  rapid, 
but  it  usually  appears  to  be  rapid  at  the  wrist,  even  though  the 
heart  is  beating  slowly. 

PERCUSSION. — The  heart  is  of  normal  size  in  fatty  degenera- 
tion, but  slightly  enlarged  in  fatty  deposit. 

AUSCULTATION. — The  first  sound  is  feeble,  short,  and  valvu- 
lar, having  lost  nearly  all  of  its  muscular  element ;  it  is  some- 
times inaudible.  The  second  sound  is  usually  short,  clacking, 
and  distant. 

A  soft,  blowing  murmur  may  frequently  be  heard  over  the 
aorta  with  the  first  sound,  especially  if  the  patient  is  in  the 
recumbent  position. 

Exceptional. — Sometimes  the  heart-sounds  in  this  disease  are  like  those  of  the 
fcetus  in  utero.  Sometimes  they  are  metallic  or  ringing,  and  it  is  said  that  the  second 
sound  is  sometimes  prolonged  and  intensified. 

Stokes  considers  the  occurrence  of  pseudo-apoplexy  with  a 
soft  souffle  in  the  aortic  area  with  the  first  sound  of  the  heart,, 
and  a  slow  pulse,  positive  evidence  of  fatty  degeneration  of  the 
heart ;  but  these  signs  seldom  occur  combined  in  the  same  indi- 
vidual. 

A  combination  of  several  of  the  important  symptoms  and 
signs  which  have  been  enumerated  is  often  present,  and  may 
justify  a  positive  diagnosis. 

DIFFERENTIAL  DIAGNOSIS. 

Fatty  heart  is  most  likely  to  be  mistaken  for  functional  affec- 
tions of  the  organ,  from  which  it  can  only  be  distinguished  by 
careful  scrutiny  of  the  symptoms  and  signs  already  enumer- 
ated, and  the  exclusion  of  hysterical  affections. 


22g  THE  HEART  AND  AORTA. 

TREATMENT. 

The  general  treatment  for  this  affection  is  the  same  as  for 
valvular  diseases. 

Arsenic  is  one  of  our  best  remedies,  as  it  not  only  increases 
the  power  of  the  heart,  but  also  relieves  the  neuralgic  pains, 
which  are  among  the  most  distressing  symptoms  of  this  disease. 
When  the  affection  consists  of  fatty  deposit  on  the  surface  of 
the  heart,  or  between  its  muscular  fibres,  much  may  be  accom- 
plished by  regulation  of  the  diet.  In  these  cases  the  patient 
should  live  principally  on  lean  meat,  and  should  avoid,  as  far  as 
possible,  all  fat-producing  food,  such  as  sugar,  starch,  and  alco- 
holic stimulants.  He  should  take  as  little  fluid  as  possible,  and 
should  wear  warm  clothing,  even  in  summer,  to  favor  free  dia- 
phoresis. These  measures  will  greatly  lessen  obesity. 

Fucus  vesiculosis  (bladder-wrack)  has  obtained  some  repu- 
tation for  reducing  obesity,  but  I  have  had  no  experience  with  it. 

MYOCARDITIS. 

Myocarditis  consists  of  an  inflammation  of  the  muscular 
fibres  of  the  heart. 

This  is  a  rare  affection,  and  of  its  symptoms  and  signs  we 
know  nothing,  apart  from  its  association  with  endocarditis  or 
pericarditis.  If,  during  the  progress  of  either  of  these  dis- 
eases, the  heart's  action  becomes  intermittent  or  irregular,  and 
there  is  a  tendency  to  syncope,  it  is  probable  that  the  muscular 
tissue  of  the  organ  has  become  involved. 

SYMPTOMS  AND  SIGNS. 

The  essential  symptoms  and  signs  of  the  disease  are :  extreme 
pallor  of  the  countenance,  with  coldness  of  the  surface  and  a 
tendency  to  syncope ;  also  pain  and  oppression  at  the  prsecor- 
dia,  with  dyspnoea  amounting  to  orthopncea,  and  suspirious 
respiration.  The  action  of  the  heart  is  feeble,  fluttering,  and 
irregular.  The  area  of  cardiac  dulness  remains  normal  unless 
pericarditis  exists.  Both  sounds  of  the  heart  are  sharp  and  val- 
vular, the  first  very  closely  resembling  the  second.  They  may 
sometimes  be  represented  by  the  "  fa,  ta  "  characteristic  of  the 
fcetal  heart.  Frequently  with  these  symptoms  and  signs  the 
patient  complains  of  severe  pain  in  the  head  and  limbs,  and 
there  may  be  delirium  or  hemiplegia.  All  or  only  a  part  of 


RUPTURE   OF   THE   HEART.  22g 

these  signs  and  symptoms  may  be  present  in  any  individual 
instance. 

DIAGNOSIS. 

If  an  acute  affection  of  the  heart  is  attended  with  pallor  and 
coldness  of  the  surface,  syncope,  pain  in  the  cardiac  region, 
and  a  feeble,  fluttering,  and  irregular  pulsation,  we  may  fairly 
suspect  inflammation  of  its  muscular  walls.  Inflammation  of 
the  cardiac  walls  may  eventuate  in  circumscribed  dilatation  or 
in  abscess,  and  finally  in  rupture  of  the  heart. 

TREATMENT. 

Treatment  should  be  the  same  as  for  endocarditis. 

ACUTE  ANEURISM  OF  THE   HEART. 

This  consists  of  bulging  of  that  portion  of  the  cardiac  walls 
which  Has  been  softened  by  inflammation. 

There  are  no  symptoms  or  signs  to  distinguish  it  from  myo- 
carditis. It  usually  eventuates  in  rupture  of  the  heart. 

ABSCESS  OF  THE  HEART. 

This  is  one  of  the  results  of  myocarditis;  therefore  it  pos- 
sesses similar  symptoms  and  signs.  The  course  of  the  disease 
is  rapid,  and,  unfortunately,  the  diagnosis  is  usually  made  only 
at  the  autopsy. 

If  the  abscess  opens  into  the  pericardium,  purulent  pericar- 
ditis supervenes  ;  if  into  one  of  the  cavities  of  the  heart,  pyaemia 
follows. 

TREATMENT. 

Treatment  should  be  the  same  as  for  endocarditis. 

RUPTURE  OF  THE  HEART. 

This  accident  may  follow  myocarditis  or  fatty  degeneration 
of  the  heart.  In  the  latter  case,  it  seldom  occurs  in  persons  less 
than  sixty  years  of  age. 

SYMPTOMS. 

The  symptoms  are:  sharp  sudden  pain  in  the  praecordial 
region,  faintness,  collapse,  and  speedy  death ;  though  some 
patients  have  lived  forty-eight  hours  after  the  accident. 


THE   HEART   AND   AORTA. 
SIGNS. 

Death  is  usually  so  sudden  that  an  examination  cannot  be 
made,  but  the  signs  must  of  necessity  be  those  of  distention  of 
the  pericardium  by  fluid,  with  extreme  weakness  of  the  heart. 

TREATMENT. 

Treatment  would  be  unavailing. 

FIBROID  DISEASE  OF  THE  HEART. 

Synonyms. — Fibroid  infiltration,  connective  tissue  hypertro- 
phy, cirrhosis  of  the  heart,  chronic  myocarditis. 

This  is  one  of  the  very  rare  diseases  of  the  heart.  It  consists 
of  a  diffused  or  circumscribed  increase  in  the  interstitial  con- 
nective tissue,  with  or  without  atrophy  of  the  muscular  fibres. 

SYMPTOMS. 

The  symptoms  which  have  been  most  frequently  noticed  are 
cardiac  pain,  oedema,  dyspnoea,  a  weak  slow  pulse,  and  irregu- 
larity of  the  heart's  action,  but  all  of  these  may  be  absent. 

SIGNS. 

There  are  no  distinctive  signs.  The  heart's  impulse  is  feeble, 
and  there  may  be  a  systolic  murmur. 

DIAGNOSIS. 

Neither  the  symptoms,  nor  signs,  or  these  combined  are 
sufficient  to  distinguish  this  condition  from  dilatation  or  fatty 
degeneration  of  the  heart ;  so  that  the  diagnosis  must  be  made 
post-mortem.  This  is  a  matter  of  little  moment,  as  the  proper 
treatment  would  be  the  same  as  that  for  other  conditions  caus- 
ing weakness  of  the  heart. 

SYPHILITIC  DISEASE  OF  THE  HEART. 

A  few  cases  have  been  observed  where  heart  disease  seemed 
to  have  resulted  from  constitutional  syphilis.  Syphilitic  affec- 
tions of  this  organ  consist  of  fibrinous  exudations  into  the  con- 
nective tissue  which  may  either  soften  and  suppurate,  forming 
ulcers  or  small  abscesses,  or  may  be  converted  into  masses  of 
hardened  fibroid  tissue ;  and  it  is  not  improbable  that,  as  sug- 
gested by  Corvisart,  vegetations  on  the  valves  may  in  some 


ULCERATIVE   ENDOCARDITIS.  2,t 

cases  have  a  syphilitic  origin.  An  accurate  diagnosis  is  impos- 
sible. No  treatment  can  be  suggested  where  a  diagnosis  can- 
not be  made. 

ULCERATIVE   ENDOCARDITIS. 

This  is  an  acute  destructive  disease  of  the  valves,  supposed 
to  be  caused  most  frequently  by  pyaemia ;  but  according  to 
Virchow,  it  is  not  infrequently  found  to  occur  in  the  latter 
months  of  pregnancy.  It  is  also  apparently  due  in  some  cases 
to  acute  rheumatism.  In  other  cases  it  cannot  be  traced  to  any 
known  cause.  This  affection  is  most  often  denoted  by  symp- 
toms and  signs  similar  to  those  of  myocarditis. 
SYMPTOMS  AND  SIGNS. 

The  principal  symptoms  are  those  of  enteric  fever.  The 
attack  is  often  ushered  in  by  a  chill,  which  is  followed  by  pros- 
tration, delirium,  or  coma.  The  temperature  usually  ranges 
from  two  to  four  degrees  F.  higher  than  normal.  The  tongue 
is  often  dry  and  brown ;  vomiting  and  diarrhoea  are  common. 
The  pulse  is  quick  and  irregular,  and  sometimes  there  are  prse- 
cordial  pains  and  palpitation  of  the  heart,  with  dyspnoea  and 
occasionally  articular  pains. 

Sometimes  no  signs  whatever  are  present,  but  in  other 
instances  auscultation  enables  us  to  detect  the  signs  of  valvular 
disease,  and  repeated  examination  may  show  that  changes  in 
the  valves  are  rapidly  progressing. 

DIAGNOSIS. 

The  absence  of  cardiac  symptoms  in  many  cases  is  likely  to 
mislead  the  physician  into  the  diagnosis  of  intermittent  or 
typhoid  fever,  or  of  pyaemia ;  but  if  attention  is  directed  to  the 
heart,  and  it  is  known  to  have  been  previously  healthy,  the 
occurrence  of  a  systolic  mitral  or  tricuspid  murmur,  with  the 
symptoms  just  mentioned,  renders  the  diagnosis  reasonably 
certain. 

TREATMENT. 

This  affection  results  from  pyaemia  or  septicaemia,  and  con- 
sequently requires  the  most  vigorous  supporting  measures. 
Large  doses  of  quinine  or  alcoholic  stimulants  are  indicated. 


2,2  THE   HEART   AND   AORTA. 


VALVULAR   DISEASE   OF    THE    HEART. 

Affections  of  the  various  valves  are  diagnosticated  by  the 
detection  of  the  murmurs  spoken  of  in  a  former  lecture,  page 
195.  Nearly  all  of  these  affections  sooner  or  later  cause  irreg- 
ularity of  the  heart's  action,  lividity  of  the  lips,  oedema,  and 
dyspnoea  on  exertion. 

TREATMENT. 

In  the  treatment  of  valvular  lesions,  three  things  are  con- 
stantly to  be  borne  in  mind. 

First.  The  labor  of  the  heart  must  be  rendered  as  light  as 
possible. 

Second.  The  blood  must  be  kept  in  a  healthy  condition. 

Third.  The  strength  of  the  heart  must  be  maintained. 

With  the  first  object  in  view,  we  interdict  rapid  walking, 
running,  or  heavy  lifting,  and  enjoin  the  patient  to  avoid 
climbing  stairs,  and  indeed  every  act  or  form  of  exercise, 
mental  or  physical,  which  causes  dyspnoea  and  palpitation  of 
the  heart.  We  attempt  also  by  proper  treatment  to  remove 
all  obstruction  to  the  circulation.  This  obstruction  may  occur 
in  the  lungs,  in  which  case  the  pulmonary  diseases  must  receive 
appropriate  treatment.  Even  a  simple  bronchitis  may  be  suffi- 
cient to  greatly  obstruct  the  circulation  through  the  pulmonary 
circuit.  The  obstruction  may  result  from  portal  congestion, 
which  must  then  be  relieved ;  or  it  may  occur  in  the  capillaries 
throughout  the  body,  which  may  be  contracted  as  the  result  of 
nervous  irritation  caused  by  the  retained  excreta  in  Bright's 
disease. 

We  must  remember  that  affections  of  the  lungs,  the  liver,  the 
alimentary  canal,  the  kidneys,  or  the  skin,  may  have  caused  the 
cardiac  disease,  or  may  greatly  aggravate  it.  Therefore  when- 
ever found  these  must  be  combated  by  appropriate  treatment. 

With  the  second  object  in  view  we  recommend  vegetable 
tonics,  iron,  and  nutritious  diet,  with  regular  habits  and  gentle 
exercise. 

To  accomplish  the  third  object,  besides  the  means  already 
suggested  for  relieving  the  heart  of  work  and  for  furnishing  it 
with  proper  nutrition,  we  prohibit  the  use  of  tobacco  and  of 


VALVULAR   DISEASE   OF   THE    HEART.  333 

all  other  depressing  agents ;  and  we  administer  various  heart 
tonics,  chief  among  which  are  digitalis,  arsenic,  and  cactus 
grandiflora.  Belladonna  and  squills  have  a  tonic  effect  on  the 
heart  similar  to  these  though  less  potent.  In  many  cases  nux 
vomica  is  a  most  useful  remedy.  Though  the  remedies  directed 
to  the  heart  itself  are  of  the  greatest  service  in  the  treatment  of 
valvular  disease,  they  should  not  be  used  indiscriminately,  for 
the  apparent  weakness  may  sometimes  be  much  more  effectu- 
ally overcome  by  medicines  which  act  upon  some  other  organ. 

In  aortic  obstruction  or  regurgitation  it  is  especially  important 
to  avoid  taxing  the  power  of  the  heart,  and  to  maintain  its 
strength  by  cardiac  tonics  and  a  good  supply  of  rich  blood. 
Nature  always  attempts  to  compensate  for  the  obstruction  or 
regurgitation  by  hypertrophy  of  the  left  ventricle ;  but  a  time 
will  finally  come  when  the  compensation  will  fail,  and  then 
digitalis  should  be  given  to  strengthen  the  muscular  walls. 
Ten  minims  of  the  tincture  of  digitalis  three  times  a  day  is  the 
ordinary  dose,  but  the  amount  may  be  gradually  increased 
until  the  heart  is  made  to  pulsate  regularly  and  with  normal 
force,  providing  the  kidneys  act  freely  and  the  stomach  is  not 
deranged.  Twenty  minims  may  be  given  as  often  as  every 
two  hours,  without  danger,  if  there  is  a  free  secretion  of  urine ; 
but  if  the  flow  stops,  the  digitalis  must  be  at  once  suspended. 

In  mitral  obstruction  or  regurgitation  digitalis  usually  has  the 
best  effects.  It  should  be  given  as  just  recommended  for  aortic 
disease.  When  it  loses  its  effects,  arsenic  or  nux  vomica  should 
be  tried,  or  these  may  be  given  with  the  digitalis.  Other  diu- 
retics, vapor  or  hot-air  baths,  and  cathartics  will  be  required 
from  time  to  time,  to  relieve  pulmonary  congestion  and  oedema, 
or  general  dropsy.  It  is  important  to  continue  the  use  of  car- 
diac tonics  for  many  months  after  the  distressing  symptoms,  for 
which  we  were  first  called,  have  passed  away ;  but  the  amount 
must  always  be  carefully  regulated,  so  as  not  to  over-stimulate 
the  organ. 

Disease  of  the  pulmonary  valves  requires  similar  treatment  to 
that  recommended  for  mitral  affections. 

In  tricuspid  regurgitation  the  same  general  rules  laid  down 
for  the  treatment  of  other  valvular  lesions  are  to  be  followed  ; 
but  unless  mitral  disease  co-exists,  digitalis  will  do  more  harm 


234  THE  HEART  AND  AORTA- 

than  good,  by  increasing  the  venous  congestion  of  the  brain 
and  of  the  abdominal  organs. 


MORBUS  C^ERULEUS. 

Synonyms. — Cyanosis  or  the  blue  disease. 

This  condition  is  the  result  of  congenital  malformation  of  the 
heart,  which  allows  the  venous  and  arterial  blood  to  commin- 
gle so  as  to  be  imperfectly  oxygenated. 

SYMPTOMS  AND  SIGNS. 

The  affection  is  indicated  by  a  deep  purple  or  bluish  color 
of  the  surface,  which  is  generally  associated  with  dyspnoea, 
frequent  palpitations,  and  cough. 

Systolic  murmurs  and  thrill  are  found  over  the  heart  or  in 
the  pulmonary  area. 

DIAGNOSIS. 

In  the  London  Lancet,  May,  1879,  Dr.  Sansom  formulates 
the  following  propositions  relating  to  the  diagnosis  of  congen- 
ital disease  of  the  heart  in  children. 

First,  in  cases  of  congenital  cyanosis,  in  which  no  cardiac 
murmur  is  manifest,  there  is  probably  patency  of  the  foramen 
ovale. 

Second,  in  cases  of  cyanosis  with  murmur  varying  at  inter- 
vals, and  heard  over  the  sternal  ends  of  the  third  and  fourth 
costal  cartilages  and  intercostal  spaces,  there  is  probably  pat- 
ency of  the  foramen  ovale. 

Third,  in  cases  of  cyanosis  with  loud  unvarying  systolic 
murmur,  with  maximum  intensity  internal  to  the  position  of 
the  apex-beat,  but  heard  also  at  the  back  between  the  scapulas, 
there  is  probably  imperfection  of  the  ventricular  septum. 

Fourth,  in  cases  of  cyanosis  and  of  marked  anaemia,  in  chil- 
dren who  manifest  a  pronounced  superficial  systolic  murmur 
at  the  base  of  the  heart,  there  is  probably  constriction  of  the 
pulmonary  artery  at  its  orifice.  Such  murmurs  may  be  asso- 
ciated with  anaemic  murmurs  which  are  heard  above  the 
clavicles. 

Fifth,  in  cases  of  congenital  affection  of  the  heart,  in  which 
there  is  evidence  oi  considerable  dilatation  of  the  left  chambers, 


NEUROTIC  OR  FUNCTIONAL  DISEASE.  ?-,e 

235 

it  is  probable  that  endocarditis  affecting  the  valves  has  consti- 
tuted a  complication. 

TREATMENT. 

No  specific  treatment  can  be  recommended,  but  the  same 
general  rules  should  be  observed  as  in  cases  of  valvular  disease 
of  the  heart. 


NEUROTIC  OR  FUNCTIONAL   DISEASE  OF   THE  HEART. 

This  affection  ordinarily  manifests  itself  by  frequent  pal- 
pitations and  irregularity  of  the  heart's  action.  It  is  stated 
by  Balfour,  that  if  a  patient  come  to  you  complaining  of  dis- 
ease of  the  heart,  you  may,  in  the  majority  of  cases,  assure 
him  that  it  is  only  a  functional  affection,  and  that  no  organic 
disease  exists;  for  the  latter  generally  escapes  notice  until 
detected  by  the  physician. 

SIGNS. 

In  functional  disease  of  the  heart,  physical  diagnosis  is  of 
importance  so  far  as  it  aids  us  in  excluding  organic  disease ; 
but  the  physical  signs  of  the  neurotic  affection  are  in  no  way 
characteristic. 

INSPECTION  AND  PALPATION. — By  inspection  and  palpation 
we  find  the  apex  in  its  normal  position,  but  usually  the  impulse 
is  comparatively  feeble,  though  the  stroke  may  seem  sharp 
and  quick ;  the  action  of  the  heart  is  usually  irregular. 

PERCUSSION  shows  the  heart  to  be  of  normal  size. 

AUSCULTATION. — Both  sounds  of  the  heart  are  abrupt,  and 
they  may  be  intensified.  Occasionally  the  first  sound  has  a 
metallic  character.  Frequently  anaemic  murmurs  are  found  in 
the  aortic  area  and  also  in  a  space  which  has  been  improperly 
termed  the  pulmonary  area,  viz.,  a  limited  area,  an  inch  or  an 
inch  and  a  half  to  the  left  of  the  sternum  in  the  second  inter- 
costal space.  The  murmurs  in  the  latter  position  seem  due  to 
a  weakened  condition  of  the  left  ventricle  which  allows  dilata- 
tion to  such  an  extent  that  the  mitral  valves  are  unable  com- 
pletely to  close  the  auriculo-ventricular  orifice,  and  slight 
regurgitation  results.  In  such  cases  the  dilatation  disappears, 
and  consequently  the  murmur  ceases  as  the  muscles  regain 
their  tonicity. 


236  THE  HEART  AND  AORTA. 

The  symptoms  of  functional  disease  of  the  heart  may  be 
associated  with  the  signs  of  organic  lesions  merely  as  a  coinci- 
dence. In  such  instances  an  exact  diagnosis  would  be  extremely 
difficult.  It  could  only  be  made  by  repeated,  careful  examina- 
tions and  by  the  evidence  afforded  by  treatment,  under  which 
many  of  the  functional  signs  may  have  disappeared. 

TREATMENT. 

The  first  thing  in  these  cases  is  to  impress  upon  the  patient 
the  fact  that  his  heart-symptoms  are  not  due  to  organic  dis- 
ease, and  that  he  is  likely  to  recover  entirely.  This  must  be 
done  after  a  careful  and  painstaking  examination.  Remem- 
bering that  neurotic  affections  of  the  heart  are  usually  due  to 
anaemia,  hysteria,  uterine  irritation,  sexual  abuses,  or  the  ex- 
cessive use  of  alcoholic  stimulants,  or  of  tobacco,  or  of  tea  and 
coffee,  we  should  ascertain  which  of  these  operates  in  the  case 
before  us  and  advise  accordingly. 

Attacks  of  angina  pectoris  are  most  promptly  relieved  by 
morphia  or  by  chloroform.  The  latter  would  seem  a  dangerous 
remedy,  but  when  used  as  recommended  by  G.  W.  Balfour,  of 
Edinburgh,  I  have  found  it  harmless,  prompt,  and  efficient.  In 
using  this  remedy,  half  a  teaspoonful  should  be  placed  in  a 
sponge  in  the  bottom  of  a  small  wide-mouthed  bottle ;  and  the 
patient  should  be  allowed  to  breathe  from  it  ad  libitum  until 
the  pain  is  relieved.  As  soon  as  the  patient  becomes  partially 
unconscious  he  will  drop  the  bottle,  and  with  it  rolls  away  all 
danger  which  might  be  apprehended  from  the  anaesthetic. 

During  the  intervals  between  the  attacks  of  angina,  the  same 
hygienic  rules  should  be  observed  as  in  valvular  disease. 
Arsenic  should  be  given  in  moderate  doses,  with  or  without 
iron,  strychnia,  and  digitalis,  according  to  special  indications. 


LECTURE  XXII. 

DISEASES  OF  THE  THORACIC  ARTERIES. 
AORTITIS. 

The  symptoms  ascribed  to  acute  exudative  inflammation  of 
the  aorta  have  been  described  by  Frank,  Bizot,  and  others,  but 
as  stated  by  R.  Douglass  Powell,  the  disease  as  a  primary 
affection  is  of  very  doubtful,  if  not  impossible,  occurrence.  We 
need  not  attempt  to  describe  any  of  the  signs  or  symptoms  it 
might  possibly^  occasion. 

ATHEROMA  OF  THE  AORTA. 

Synonyms. — Aortic  endarteritis  ;  Atheromatous  degeneration 
of  the  aorta. 

This  may  be  defined  as  a  degeneration  of  the  coats  of  the 
aorta,  consisting  of  an  irregular  thickening  and  softening 
of  its  walls,  especially  of  its  inner  coat,  with  consequent 
fatty  degeneration  of  the  affected  parts,  and  fibroid  thick- 
ening of  the  entire  wall  of  the  vessel ;  and  finally  breaking- 
down  or  calcareous  degeneration  of  the  internal  or  middle 
coat.  As  the  result  of  these  changes  there  is  usually,  at  first, 
narrowing  of  the  calibre  of  the  aorta  or  roughening  of  its  inner 
surface,  which  interferes  with  the  natural  current  of  blood,  and 
thus  gives  rise  to  abnormal  signs.  This  condition  is  sooner  or 
later  followed  by  dilatation  of  the  vessel. 

The  affection  is  usually  limited  to  the  initial  portion  of  the 
blood-vessel;  and  indeed,  clinical  evidence  of  its  existence 
beyond  the  transverse  portion  of  the  arch  is  very  rare. 

SYMPTOMS  AND  SIGNS. 

The  symptoms  of  this  disease  are  always  obscure,  and  its 
physical  signs,  in  many  cases,  are  far  from  positive.  Among 
the  most  prominent  symptoms  and  signs  we  observe  attacks  of 


-    c 


THE  HEART  AND  AORTA. 


palpitation,  or  pain  and  dyspnoea  termed  angina,  which  often 
occur  independent  of  exertion,  but  are  also  brought  on  by 
exercise.  During  these  attacks  the  pulse  is  very  weak,  but  at 
other  times  its  rhythm  may  be  normal.  The  temporal,  radial, 
and  brachial  arteries  are  sometimes  rigid  and  less  elastic  than 
in  the  healthy  condition,  on  account  of  an  atheromatous  condi- 
tion of  the  arteries  in  general 

INSPECTION  AND  PALPATIOX.  —  When  dilatation  has  taken 
place,  feeble  pulsation  may  be  seen  or  felt  in  the  second  inter- 
costal space,  dose  to  the  sternum,  on  the  right  side. 

PERCUSSION  —  Upon  percussion  there  is  found  a  somewhat 
increased  area  of  dulness  over  the  ascending  or  transverse 
portion  of  the  aorta. 

AUSCULTATION.  —  Early  in  the  disease  there  may  be  some 
evidence  of  hypertrophy  of  the  left  ventricle,  as  indicated  by 
an  increased  impulse  and  muffling  of  the  first  sound  of  the 
heart.  These  signs,  however,  are  not  characteristic,  as  they 
might  easily  be  accounted  for  by  co-existing  emphysema  or 
other  cause  of  obstructed  circulation. 

With  the  advent  of  dilatation,  the  first  sound  of  the  heart 
IrrtiMnfi  more  indistinct,  while  the  second  sound  over  the 
aortic  udics  is  accentuated.  Accentuation  of  the  second 
sound  in  this  locality  is  thought  by  some  to  be  diagnostic  of 
of  the  aorta.  A  short  murmur  is  usually  heard  over 


the  aorta,  immediately  after  the  systole  of  the  ventricles, 
especially  when  the  action  of  the  heart  is  rapid.  As  dilatation 
progresses,  the  bruit  becomes  more  and  more  distinct.  It  is 
sometimes  rough  in  character,  and  it  may  be  associated  with  a 
purring  tremor. 

The  second  sound  may  be  partially  supplanted  by  a  faint 
diastolic  murmur,  due  to  dilatation  at  the  origin  of  the  artery  ; 
which  renders  the  semOnnar  valves  incompetent  to  dose  the 
orifice,  and  allows  legnrgitation  into  the  ventricles. 

When  the  heart  is  beating  slowly  and  regularly,  both  the 
first  and  second  sounds  may  be  accentuated  over  the  upper 
part  of  the  sternum  ;  and  the  systole  of  the  heart  may  be  at- 
tended by  a  slight  impulse,  which  can  be  appreciated  by  the 
ear.  Bat  rhislattersign,  to  be  of  value,  must  be  obtained  when 
the  patient  is  perfectly  quiet. 

Later  in  the  disease,  dyspnoea  becomes  marked  ;  the  attacks 


ANEURISMS  OF  THE  felNCSES  OF  VALSALVA, 

of  angina  are  more  frequent  and  persistent ;  and  the  symp- 
toms of  embolism,  that  is,  hemiplegia,  rigors,  haemafuria, 
superficial  hemorrhages,  or  gangrene  may  make  their  appear- 
ance; or  the  formation  of  a  sacculated  aneurism  from  the  affected 
portion  of  the  artery  may  be  indicated  by  the  sudden  occur- 
rence of  pain,  dyspnoea,  and  faintness.  Finally,  sudden  death 
may  result  from  bean-failure  or  from  rupture  of  the  aorta. 

DIFFERENTIAL  DIAGNOSIS. 

The  principal  symptoms  and  signs  of  this  affection  are  palpi- 
tation, pain,  and  dyspnoea;  with  rigidity  of  the  *Ji|*f*^-i»l 
arteries,  muffling  of  the  first  sound  of  the  heart,  and  accentua- 
tion of  the  second  sound,  over  the  aortic  valves.  The  first 
heart-sound  is  usually  followed  by  a  more  or  lem  «!•*•••• '••  sys- 
tolic murmur.  Sometimes  there  is  a  diastoup  murmur  in  the 
region  of  the  ascending  or  transverse  portion  of  the  arch  of  the 
aorta,  with  slight  increase  in  the  area  of  dulness  during  the 
later  stages.  The  affection  might  be  mistaken  for  simple  dis- 
ease of  the  aortic  valves,  or  inorganic  disease  of  the  heart,  with 
anaemic  murmurs. 

Disease  of  the  aortic  vahxs,  though  it  may  cause  all  the  other 
symptoms  and  signs  of  atheroma,  is  not  attended  by  a  rigid 
condition  of  the  superficial  arteries.  It  does  not  cause  the 
peculiar  neuralgic  pains  which  usually  attend  atheroma,  and 
it  does  not  cause  accentuation  of  the  second  sound  at  the  aortic 
valves  or  an  increased  area  of  dulness. 

Amofmic  murmurs  associated  with  functional  disease  of  the 
heart  are  not  attended  by  rigidity  of  the  superficial  arteries; 
by  the  peculiarly  distinct  accentuation  of  the  second  sound ; 
by  the  systolic  shock ;  or  by  the  diastolic  bruit ;  or  by  increased 
area  of  dulness. 

TREATMENT. 

Morphia  or  some  of  the  antispasmodic  remedies  are  indi- 
cated during  the  attacks  of  dyspnoea.  Iodide  of  potassium  in 
moderate  doses  is  sometimes  usefuL  Excessive  exertion  must 
be  avoided. 

ANEURISMS  OF  THE  SOTUSES  OF  TAUSALVA, 

Aneurisms  in  this  position  are  usually  so  small  as  togive  rise 
to  no  peculiar  symptoms  or  signs.  The  symptoms  and  signs 


THE    HEART   AND   AORTA. 
\ 

of  atheromatous  degeneration,  with  a  pulmonary  systolic  or 
diastolic  murmur  due  to  pressure  of  the  aneurism  on  the  origin 
of  the  pulmonary  artery,  might  lead  us  to  suspect  the  true 
nature  of  the  lesion.  The  diagnosis  can  rarely,  if  ever,  be 
made  with  certainty,  as  the  tumor  lies  enveloped  in  the  peri 
cardium,  so  close  to  the  heart  that  it  is  almost  impossible  to 
distinguish  between  the  murmurs  which  it  produces  and  those 
of  valvular  origin. 


ANEURISM   OF  THE  THORACIC  AORTA. 

This  consists  of  preternatural  dilatation  of  the  artery,  which 
may  be  general,  that  is,  involving  the  whole  circumference  in 
a  fusiform  cylindrical  or  globular  swelling;  or  sacculated,  that 
is,  springing  from  one  side  of  the  artery  in  a  sort  of  pouch. 

Sacculated  aneurisms' are  usually  globular  at  first,  but  they 
may  subsequently  acquire  different  forms,  especially  the  con- 
ical. 

The  smaller  of  the  fusiform  aneurisms  are  usually  spoken  of 
as  atheroma  of  the  aorta. 

Aneurisms  may  occur  at  the  sinuses  of  Valsalva,  or  in  the 
ascending,  transverse,  or  descending  portion  of  the  arch  of  the 
aorta.  Nearly  one  fifth  of  these  aneurisms  spring  from  the 
sinuses  of  Valsalva.  About  two  fifths  have  their  origin  in  the 
ascending  portion  of  the  arch ;  a  few  involve  both  the  ascend- 
ing and  the  transverse,  or  simply  the  transverse  portion  of  the 
arch.  Nearly  one  fifth  arise  from  the  descending  arch,  and 
about  the  same  number  from  that  portion  of  the  aorta  between 
the  arch  and  the  diaphragm. 

SYMPTOMS. 

Tumors  of  this  character  may  sometimes  be  detected  by 
scrutinizing  the  symptoms,  when  they  cannot  be  diagnosticated 
by  the  physical  signs.  Therefore,  I  wish  to  direct  your  atten- 
tion to  a  few  of  the  more  prominent  symptoms  which,  though 
not  individually  characteristic,  may  be  sufficient  for  the  purpose 
of  diagnosis  when  grouped  together.  They  will,  at  least,  be 
of  great  value  when  taken  in  connection  with  the  physical 
signs. 

The  symptoms,  enumerated  nearly  in  the  order  of  their  im- 


ANEURISM   OF   THE   THORACIC   AORTA.  241 

portance,  are:  pain,  dyspnoea,  palpitation,  dysphagia,  head- 
ache, and  disordered  vision. 

Pain. — The  pain  in  aneurism  of  the  aorta  is  persistent,  and 
has  a  peculiar  wearing,  aching,  or  burning  character,  which  is 
referred  *to  the  region  of  the  tumor.  Frequently  there  are 
neuralgic  exacerbations,  the  pain  radiating  in  the  course  of 
contiguous  nerves. 

Dyspncea. — Dyspnoea  of  varying  degree  is  generally  present, 
and  is  usually  aggravated  by  much  slighter  causes  than  those 
which  would  occasion  the  same  symptom  in  other  varieties  of 
intra-thoracic  tumors.  It  frequently  occurs  in  severe  parox- 
ysms, which  may  be  due  to  one  of  two  or  three  causes. 
Ordinarily  these  paroxysms  are  ascribed  to  spasm  of  the  glot- 
tis, resulting  from  irritation  of  one  or  both  of  the  recurrent 
laryngeal  nerves.  A  more  probable  explanation  is  that  they 
are  due  to  paralysis  of  the  abductor  muscles  of  the  glottis, 
which  are  supplied  by  these  nerves,  with  consequent  falling- 
together  of  the  vocal  cords,  and  obstruction  of  the  glottis  dur- 
ing inspiration. 

The  exacerbations  of  this  symptom  are  due  in  some  instances 
to  a  collection  of  mucus  at  the  glottis ;  in  others  to  the  varying 
pressure  of  the  aneurism  upon  the  nerve  which,  at  one  time, 
completely  suspends  its  function,  and  at  another  interferes  with 
it  more  slightly.  The  voice  is  also  modified  more  or  less  by 
the  same  cause,  and  it  may  be  lost. 

Dyspncea  is  sometimes  dependent  upon  narrowing  of  the 
trachea  or  of  the  bronchi  from  the  pressure  of  the  aneurism. 
In  such  instances,  the  paroxysms  are  doubtless  due  to  a  collec- 
tion of  mucus  at  the  point  of  stricture,  which  the  patient  may 
be  unable  to  expectorate. 

Palpitation. — Palpitation  of  the  heart  is  generally  produced 
by  slight  exertion. 

Dyspliagia. — Dysphagia,  due  to  pressure  upon  the  oesophagus, 
is  often  present,  though  it  is  a  less  frequent  symptom  with 
aneurismal  than  with  other  tumors. 

Headache. — Headache,  due  to  interference  with  the  return  of 
blood  to  the  heart,  is  not  uncommon. 

Disordered  Vision. — The  disordered  vision  is  due  to  pressure 
upon  the  sympathetic  nerve,  with  consequent  interference  with 
the  action  of  the  iris.  Ordinarily  the  pupil  upon  the  affected 
16 


THE  HEART   AND   AORTA. 

side  is  strongly  contracted,  but,  in  rare  instances,  it  may  be 
dilated. 

Hemoptysis,  to  a  slight  degree,  is  an  occasional  symptom  due 
to  congestion  of  the  mucous  membrane.  Copious  haemoptysis 
frequently  occurs  at  the  close  of  the  disease,  when  the  aneu- 
rism ruptures  into  the  air-passages. 

SIGNS. 

The  essential  signs  are :  a  pulsating  tumor  in  the  region  of 
the  aorta,  with  systolic  and  diastolic  shock  and  sometimes 
bruits. 

INSPECTION. — Upon  inspecting  a  patient  suffering  from  aneu- 
rism of  the  aorta,  we  observe  marked  lividity  of  the  face,  neck, 
and  upper  extremities ;  with  turgescence  and  a  varicose  condi- 
tion of  the  veins,  and  perhaps  cedema,  due  to  obstruction  in  the 
return  of  blood  to  the  heart  by  pressure  of  the  aneurism  upon 
one  of  the  venae  innominatae  or  the  descending  vena  cava. 
Occasionally  a  thick  fleshy  collar  is  found  about  the  base  of 
the  neck,  due  to  capillary  turgescence. 

CEdema  and  turgescence  are  ordinarily  limited  to  one  side 
and  are  caused  by  pressure  on  one  of  the  venae  innominatae. 
If  the  pressure  is  upon  the  descending  vena  cava,  which  is 
most  likely  to  occur  with  an  aneurism  of  the  ascending  arch> 
these  signs  will  be  found  upon  both  sides. 

Upon  inspection  of  the  chest,  the  surface  is  seen  to  have  a 
marbled  appearance,  caused  by  the  prominence  and  blueness 
of  the  veins.  A  tumor  may  usually  be  observed  in  the  course 
of  the  aorta,  the  position  of  which  will  indicate  the  part  of  the 
blood-vessel  which  is  affected. 

An  aneurism  originating  in  the  sinuses  of  Valsalva  causes  no 
external  tumor.  When  it  springs  from  the  ascending  portion 
of  the  aorta,  if  bulging  occurs,  it  will  be  seen  in  the  second 
intercostal  space  at  the  right  side  of  the  sternum  ;  but  the 
tumor  may  be  large  enough  to  extend  into  the  mammary  and 
infra-clavicular  regions. 

Aneurisms  of  the  transverse  portion  of  the  arch  cause  a 
tumor  at  the  upper  part  of  the  sternum. 

When  the  descending  arch  is  involved,  tne  tumor  generally 
presents  posteriorly  at  the  left  of  the  spinal  column. 

Exceptional. — In  exceptional  cases  an  aneurism  of  this  kind  may  be  seen  in  front, 
and  in  very  rare  instances  it  may  be  found  at  the  right  of  the  spinal  column. 


ANEURISM   OF  THE   THORACIC  AORTA.  243 

Aneurisms  of  the  descending  aorta  present  posteriorly,  below 
the  fourth  dorsal  vertebra  at  the  left  of  the  spine.  Very  rarely 
they  are  seen  at  the  right  of  the  spinal  column.  These  tumors 
vary  in  size  from  a  slight  prominence  to  one  as  large  as  a 
child's  head.  The  absence  of  a  tumor  does  not  necessarily 
prove  that  no  aneurism  exists  ;  for,  while  the  aneurism  is  small, 
it  may  not  press  upon  the  chest-walls,  and  even  when  of  con- 
siderable size  the  position  may  be  such  that  no  bulging  is 
occasioned. 

The  larger  of  these  tumors  are  generally  conical  in  form,  and 
present  very  much  the  appearance  of  an  immense  boil,  covered 
by  thin,  glazed  integuments. 

If  pulsation  of  the  tumor  can  be  observed,  it  will  be  seen  to 
occur  rhythmically  with  the  apex-beat  of  the  heart.  Pulsation, 
which  cannot  otherwise  be  seen,  may  sometimes  be  detected  by 
bringing  the  eye  to  the  level  of  the  surface  of  the  chest,  as  in 
standing  behind  the  patient  and  looking  down  over  his  shou  - 
ders.  No  pulsation  will  be  visible  if  the  aneurism  is  occupied 
by  fibrine  or  coagulated  blood. 

If  the  tumor  press  on  one  of  the  main  bronchi,  the  respira- 
tory movements  on  the  corresponding  side  will  be  diminished 
or  absent. 

PALPATION. — By  palpation  we  may  frequently  detect  a  tumor, 
the  impulse  of  which  cannot  be  seen;  we  can  ascertain  the 
condition  of  the  chest-walls,  whether  there  be  perforation  of 
the  costal  cartilages,  sternum,  or  ribs;  and  we  may  usually 
determine  whether  the  contents  of  the  tumor  are  fluid  or  solid. 
By  this  method  we  also  learn  the  character  of  the  pulsation, 
which,  in  aneurism,  is  expansile,  that  is,  alike  in  every  direc- 
tion, and  not  simply  lifting,  as  is  the  case  when  a  solid  tumor 
rests  upon  an  artery. 

The  most  valuable  sign  obtained  by  this  method  is  the 
detection  of  two  pulsating  points ;  as  though  there  were  two 
hearts,  one  beating  in  the  normal  position  in  the  fifth  interspace, 
and  the  other  above  the  third  rib. 

If  the  aneurism  is  so  small  as  to  escape  observation  by  ordinary  palpation,  it  may 
sometimes  be  detected  by  pressing  firmly  with  one  hand  over  the  aorta  in  front,  and 
with  the  other  posteriorly. 

The  impulse  obtained  over  an  aneurism  may  be  systolic,  tha 
is,  occurring  with  the  contraction  of  the  ventricles ;  or  it  may 


THE    HEART   AND   AORTA. 

be  both  systolic  and  diastolic.  The  latter  is  produced  by  con- 
traction of  the  artery,  and  is  usually  slight,  but  it  is  sometimes 
quite  forcible.  When  found  it  is  a  valuable  sign. 

Frequently  these  tumors  give  rise  to  a  peculiar  thrill,  similar 
to  the  purring  tremor ;  and  sometimes  very  early  in  the  course 
of  an  aneurism  of  the  tranverse  arch,  an  impulse  or  a  thrill 
may  be  felt  by  thrusting  the  finger  downward  behind  the  epi- 
sternal  notch. 

Valuable  information  may  be  obtained  in  some  cases  by  pal- 
pation of  the  pulse  or  from  sphygmographic  tracings  (Fig.  36, 
page  208).  If  the  aneurism  press  upon  the  arteria  innominata, 
or  upon  either  of  the  subclavian  arteries,  or  if  either  of  these 
vessels  is  obstructed  by  a  coagulum,  the  radial  pulse  will  be 
feebler  upon  the  corresponding  side  than  upon  the  other.  The 
carotids  are  sometimes  similarly  affected.  If  atheromatous 
degeneration  of  the  arteries  be  general,  the  superficial  arteries, 
especially  the  radial  and  temporal,  will  be  found  rigid  and  non- 
elastic. 

Alterations  in  the  movements  of  the  chest-walls  and  in  the 
vocal  fremitus  are  also  to  be  sought  for  by  palpation.  Press- 
ure on  the  air-passages  will  diminish  the  respiratory  move- 
ments, and  cause  local  or  general  diminution  or  absence  of 
the  vocal  fremitus,  according  as  a  bronchus  or  the  trachea 
is  obstructed  or  the  lung  itself  compressed. 

PERCUSSION. — Percussion  must  be  performed  gently,  espec- 
ially over  large  aneurisms,  as  a  forcible  stroke  might  possibly 
cause  rupture  of  the  weakened  blood-vessel.  Upon  gentle 
percussion,  the  extent  of  dulness  will  not  correspond  to  the 
size  of  the  tumor,  on  account  of  the  overlapping  borders  of  the 
lungs ;  but  by  a  more  forcible  stroke,  or  by  auscultatory  percus- 
sion, we  may  determine  the  limits  accurately. 

The  area  of  abnormal  dulness  is  usually  much  smaller  than 
in  other  tumors,  causing  symptoms  of  equal  gravity. 

The  sense  of  resistance  felt  upon  percussion  is  a  valuable 
sign  in  distinguishing  between  aneurisms  and  other  intra-tho- 
racic  tumors.  Over  a  tumor  filled  with  fluid,  the  resistance  is 
much  less  than  over  a  solid  growth  or  over  an  aneurism  filled 
with  fibrinous  deposits. 

If  the  aneurism  present  posteriorly,  dulness  will  be  obtained 
in  the  interscapular  region.  If  it  has  pressed  upon  a  main 


ANEURISM   OF   THE   THORACIC   AORTA,  345 

bronchus,  or  upon  one  lung,  so  as  to  cause  collapse  or  conges- 
tion of  this  organ,  dulness  will  be  found  over  the  corresponding 
side  of  the  chest. 

AUSCULTATION. — Upon  listening  over  an  aneurism,  we  first 
notice  an  impulse,  or  shock,  which  is  transmitted  through  the 
stethoscope  to  the  ear,  with  each  contraction  of  the  heart. 
This  impulse  is  frequently  immediately  followed  by  a 
second,  or  diastolic  shock,  due  to  contraction  of  the  arteries. 
The  shock  is  usually  attended  by  one  or  two  sounds  which 
consist  mainly  of  the  transmitted  heart-sounds,  but  which  are 
in  part  produced  by  dilatation  and  contraction  of  the  artery. 

These  sounds  may  be  associated  with  or  supplanted  by  mur- 
murs somewhat  similar  in  character  to  endocardial  murmurs. 
However,  they  are  ordinarily  less  intense,  though  they  may  be 
even  louder  than  the  loudest  heart-murmurs.  They  are  usually 
harsh  in  quality,  and  are  not  transmitted  into  the  same  regions 
as  endocardial  murmurs.  Sometimes  neither  sounds  nor  mur- 
murs can  be  detected  over  the  aneurism. 

If  the  tumor  press  upon  a  main  bronchus,  the  respiratory 
murmur  will  be  diminished  or  absent  upon  the  corresponding 
side,  while  on  the  opposite  side  it  will  be  exaggerated.  In 
these  instances  a  forced  inspiration  will  sometimes  distend  the 
lung,  and  bring  out  the  respiratory  murmur  where  it  could 
not  be  heard  during  ordinary  breathing.  Vocal  resonance  will 
be  diminished  or  absent  over  the  obstructed  lung,  and  absent 
over  the  aneurism.  If  the  lung  be  condensed  by  pressure, 
broncho-vesicular  respiration  may  be  heard. 

If  the  tumor  press  upon  the  recurrent  laryngeal  nerve, 
so  as  to  cause  paralysis  or  spasm  of  the  vocal  cords,  stridulous 
respiration  will  be  produced,  with  dysphagia  or  aphonia. 
Inspection  of  the  larynx  will  usually  reveal  the  existence  of 
paralysis  of  the  cord  on  the  corresponding  side,  with  possible 
paresis  of  the  opposite  cord.  Occasionally  both  nerves  are 
pressed  upon,  and  consequently  both  vocal  cords  may  be 

paralyzed. 

DIAGNOSIS. 

Venous  turgescence,  displacement  of  the  heart,  dulness  on 
percussion,  and  modifications  of  the  respiratory  sounds,  due  to 
pressure,  are  signs  common  to  these  and  to  other  varieties  of 
intra-thoracic  tumors.  Variation  in  the  force  and  volume  of 


246  THE  HEART  AND  AORTA. 

the  pulse  on  the  two  sides,  expansile  pulsation  of  the  tumor 
with  a  shock  and  bruit  are  characteristic  of  aneurisms,  but 
occasionally  even  these  signs  may  be  caused  by  solid  growths. 
A  diastolic  bruit  and  shock  over  an  intra-thoracic  tumor  accom- 
panied with  a  clear  second  sound  at  the  base  of  the  heart,  is 
diagnostic  of  aneurism,  especially  if  following  a  distinct  systolic 
bruit  and  shock.  A  murmur  at  the  base  of  the  heart,  taking 
the  place  of  the  second  sound,  when  associated  with  the  signs 
of  a  tumor,  in  the  course  of  the  aorta,  is  valuable  evidence  of 
probable  atheromatous  degeneration  of  the  aorta,  which  is  the 
usual  cause  of  aneurism. 

ANEURISM  OF  THE  ARTERIA  INNOMINATA. 

Aneurisms  of  this  artery  cause  pulsating  tumors  similar  to 
those  of  the  aorta. 

DIAGNOSIS. 

Such  an  aneurism  may  be  distinguished  from  an  aneurism  of 
the  arch  of  the  aorta — first,  by  its  position  ;  second,  by  the  com- 
parative absence  of  signs  due  to  pressure ;  and  third,  by  the 
effect  on  the  pulsation  of  compression  of  the  subclavian  and 
carotid  arteries.  An  aneurism  of  the  arteria  innominata  is 
located  entirely  upon  the  right  side  of  the  sternum,  and  causes 
a  prominence  in  the  region  of  the  inner  end  of  the  clavicle.  It 
is  not  likely  to  cause  much  pressure  upon  the  recurrent  laryn- 
geal  nerve,  with  consequent  obstruction  of  the  larynx  ;  or  on 
the  oesophagus,  so  as  to  interfere  with  deglutition  ;  or  upon  the 
trachea,  so  as  to  cause  dyspnoea.  Compression  of  the  carotid 
or  subclavian  artery,  on  the  affected  side,  greatly  diminishes 
the  pulsation  in  an  aneurism  of  this  artery,  but  does  not  affect 
the  pulsation  of  an  aneurism  involving  the  arch  of  the  aorta 
alone. 

ANEURISM  OF  THE  PULMONARY  ARTERY. 

This  is  one  of  the  rarest  affections  of  the  circulatory  system. 
From  the  few  cases  which  have  been  described,  we  are  unable 
to  obtain  any  characteristic  symptoms  or  signs.  The  principal 
symptoms  and  signs  which  have  been  noticed  are :  extreme 
cyanosis,  with  dropsy  and  great  dyspnoea,  associated  with  a 


ANEURISM   OF   THE   PULMONARY   ARTERY.  24? 

strongly  pulsating  tumor,  located  in  the  second  intercostal 
space  of  the  left  side,  and  limited  to  this  region.  This  tumor 
is  likely  to  yield  a  thrill  upon  palpation.  Upon  auscultation, 
systolic  or  diastolic  murmurs,  or  both,  may  be  detected,  but 
they  are  not  propagated  above  the  clavicles.  It  is  hardly 
possible  to  distinguish  aneurisms  of  the  pulmonary  artery  from 
those  of  the  aorta,  which  happen  to  present  to  the  left  of  the 
sternum. 

DIFFERENTIAL  DIAGNOSIS. 

Aneurisms  of  the  aorta  may  be  confounded  with  solid  tumors ; 
with  aortic  pulsation,  due  to  regurgitation  through  the  semi- 
lunar  valves  ;  with  pulsating  empyema ;  with  dilatation  of  the 
auricle ;  with  aneurism  of  the  pulmonary  artery ;  and  with 
consolidation  of  the  anterior  border  of  the  lung.  The  differen- 
tial features  are  pointed  out  in  the  following  tables. 

Aneurisms  can  only  be  distinguished  from  other  intra-tho- 
racic  tumors  by  attention  to  the  history  and  symptoms  as  well 
as  to  the  physical  signs. 

Solid  Tumors. — The  distinctive  features  between  thoracic 
aneurisms  and  solid  tumors  are  seen  below. 

ANEURISMS.  SOLID  TUMORS. 

History. 

They  seldom  or  never  occur  before  the  Usually  malignant.     They  may  occur 

twenty-fifth  year  of  age,  and  usually  not  in  early  life,  and  not  unfrequently  before 
until  after  the  forty-fifth  year.  Slight  if  the  twenty-fifth  year.  Grave  constitu- 
any  constitutional  disturbance.  tional  disturbance. 

Symptoms. 

The  pain  is  constant,  and  of  a  burning,  Pain  not  so  deep-seated  as  in  aneurisms; 

wearing,  or  aching  character;  but  fre-  it  may  be  sharp  and  lancinating  in  char- 
quently  subject  to  neuralgic  exacerba-  acter.  It  is  not  subject  to  neuralgic  ex- 
tions.  The  symptoms  and  signs  of  press-  acerbations.  The  symptoms  and  signs  of 
ure  vary  from  time  to  time,  owing  to  pressure  are  constant  and  steadily  increase 
changes  in  the  direction  of  the  pressure.  from  day  to  day. 

Sigitt. 

Expansile  pulsation.     Often   disparity  No  pulsation,  or  if  any,  simply  a  slight 

in  the  radial  pulse  of  the  two  sides.     The         lifting  impulse,  caused  by  the  tumor  rest- 
area  of  dulness  is  small  in  proportion  to         ing  upon  a  large  artery.     Usually  no  dis- 
the  size  of  the  tumor,  and  the  length  of         parity  in  the  pulse  of  the  two  sides, 
its  history.     The  sense   of   resistance   is  The    area    of    dulness    is   large,  and 

slight.  rapidly  increases.    The  sense  of  resistance 

is  well  marked. 


248  THE  HEART  AND  AORTA. 

Aortic  pulsation  is  distinguished  from  aortic  aneurism  by  the 
following  symptoms  and  signs: 

ANEURISM.  AORTIC  PULSATION. 

Symptoms. 

Symptoms  of  pressure  upon  the  trachea,  No  symptoms  of  pressure, 

oesophagus,  or  recurrent  laryngeal  nerve. 

Signs. 

Pulsation  in  a  limited  space  over  the  Pulsation  not  only  over  the  aorta,  but 

arch  of  the  aorta.  in     the    carotids,   subclavians,  and  bra- 

chials. 

The  radial  pulse  is  not  exaggerated  on  The  pulse  is  sharp  and  apparently  forci- 

either  side  by  elevation  of  arm  ;  usually  ble  ; — hammer  pulse  exaggerated  by  ele- 

it  is  feeble  on  one  side.  vation  of  the  arm,  and  alike  on  both  sides. 

Increased  area  of  aortic  dulness.  No  increase  in  the  area  of  dulness. 

Arterial    bruits,    systolic   or  diastolic,  Aortic    regurgitant    murmur,    but    no 

generally  distinct  from  endocardial  mur-  special  bruit  over  the  pulsating  vessel. 
murs. 

Pulsating  empyema  may  simulate  aneurism,  but  ordinarily  it 
can  be  easily  distinguished  by  its  position.  If,  however,  perfo- 
ration of  the  chest-walls  should  take  place  in  the  course  of  the 
aorta,  as  in  a  case  recorded  by  Prof.  Flint,  the  diagnosis  would 
be  much  more  difficult. 

ANEURISM.  PULSATING  EMPYEMA. 

Symptoms  and  Signs. 

Symptoms  and  signs  of  pressure  upon  Usually  no  symptoms  of  pressure  upon 

adjacent  organs.  the  trachea,  oesophagus,  and  other  adja- 

cent organs. 

Dulness  confined  to  the  region  of  the  Dulness  or  flatness  over  the  pulsating 

aorta.  tumor  and  also  over  the  lower  part  of  one 

side. 

Arterial  bruits.     No  pulmonary  signs,  No  bruit.     Signs  due  to  compression 

unless  there  be  pressure  upon  the  trachea,  of  the  lung  by  fluid  in  the  pleural  sac. 
bronchus,  or  lung  itself.  Expansile  pul-  Pulsation  somewhat  similar  to  that  of 
sation  of  the  tumor.  aneurisms,  but  usually  less  expansile. 

A  dilated  auricle  is  distinguished  from  an  aneurism  of  the 
aorta  as  follows  : 

ANEURISM.  DILATED  AURICLE. 

Symptoms  and  Signs. 

Signs  and  symptoms  due  to  pressure  Few,   if  any,   signs  and  symptoms  of 
upon  adjacent  organs.     Pulsation  follow-  pressure.     Pulsation  preceding  the  apex- 
ing  the  systole  of  the  ventricles  and  the  beat, 
apex-beat. 

Dulness   in   the   region  of   the   aorta.  Dulness  extending  far  beyond  the  re- 


ANEURISM   OF   THE   DESCENDING  AORTA 

Arterial  bruits  common,  but  propagated         gion  of  the  aorta,  and  usually  at  a  lower 
mostly  over  the  arteries.  level ;  usually  endocardial  murmurs  prop- 

agated in  directions  different  from  those 
of  the  aneurismal  bruit. 

Consolidation  of  the  anterior  border  of  the  lung  is  differentiated 
from  aneurism  by  the  position  of  the  dulness  and  by  the  signs 
upon  auscultation.     If  the  consolidation  is  due  to  an  aneurism,, 
care  must  be  taken  not  to  overlook  the  signs  of  the  latter. 
ANEURISM.  CONSOLIDATION  OF  THE  LUNG. 

Signs. 

Dulness  limited  to  the  course  of  the  Dulness  not  limited  to  the  aortic  region, 

aorta.  but  extending  externally,  and  usually  in- 

volving the  whole  apex  of  the  lung. 

A  normal  respiratory  murmur  may  often  Rales  and  other  signs  of  consolidation, 

be  heard  over  the  greater  portion  of  the         No  bruits, 
aneurism.     Arterial  bruits. 

An  aneurism  of  the  pulmonary  artery  is  not  likely  to  be  mis- 
taken for  an  aneurism  of  the  aorta,  because  it  is  so  very  rare. 

The  position  of  a  pulmonary  aneurism  is  different  from  that 
of  most  aneurisms  of  the  aorta.  An  aneurism  of  the  ascend- 
ing portion  of  the  aorta  might  possibly  present  to  the  left  of 
the  sternum,  though,  in  this  locality,  we  are  more  likely  to 
observe  aneurisms  of  the  descending  aorta.  The  distinctive 
features  between  aortic  aneurisms  and  those  of  the  pulmonary 
artery  may  be  stated,  from  the  symptoms  and  signs  which  have 
been  observed  up  to  the  present  time,  as  follows : 

ANEURISMS  OF  THE  AORTA.  ANEURISMS  OF  THE  PULMONARY  ARTERY. 

Aneurisms  of  the  ascending  arch  pre-  The  tumor  is  confined  to  the  second 

sent   to   the  right  of   the  sternum,   and         intercostal  space  of  the  left  side, 
those  of  the  descending  arch  usually  pre- 
sent behind,  at  the  left  of  the  third  dorsal 
vertebra,  and  very  rarely  in  front. 

Signs  and  symptoms  due  to  pressure  The  signs  of  pressure  are  comparatively 

upon  the  trachea,  bronchial  tubes,  cesoph-         slight,  but  usually  there  is  congestion    f 
agus,  blood-vessels,  or  recurrent  laryngeal         the  face,  anasarca,  and  gr^at  dyspnoea. 


nerve. 


Bruits  which  may  be  propagated  into  Bruits  not  propagated  above  the  clavi- 

the  carotids  and  subclavians.  cles. 

ANEURISM  OF  THE  DESCENDING  AORTA. 
This  affection  causes  a  pulsating  tumor  behind,  at  the  left  of 
the  spinal  column,  between  the  third  dorsal  vertebra  and  the 


2c0  THE  HEART  AND  AORTA. 

point  at  which  the  aorta  perforates  the  diaphragm.  By  press 
ure  erosion  of  the  vertebras  is  usually  produced,  with  conse- 
quent curvature  of  the  spine.  Subsequent  compression  of  the 
spinal  cord  may  cause  paraplegia.  The  tumor,  if  large,  usually 
displaces  the  heart  forward  and  to  the  right.  In  exceptional 
instances,  aneurisms  of  this  portion  of  the  aorta  may  be  detected 
upon  the  right  side  of  the  spinal  column.  The  bruit,  in  an 
aneurism  of  the  descending  aorta,  may  be  distinguished  from  a 
mitral  regurgitant  murmur,  which  is  frequently  heard  in  a 
similar  position,  by  the  fact  that  the  aneurismal  murmur  is 
heard  not  only  between  the  fifth  and  the  eighth  dorsal  verte- 
brae, but  also  above  and  below  this  position.  The  mitral 
regurgitant  murmur  is  not  heard  distinctly  above  the  lower 
border  of  the  fifth  or  below  the  upper  border  of  the  eighth 
vertebra. 

TREATMENT   OF   ANEURISMS. 

Two  methods  of  treatment  have  been  successfully  employed 
in  a  few  cases  for  the  relief  or  the  cure  of  intra-thoracic  aneu- 
risms. 

Tufnell's  method,  which  in  several  cases  has  succeeded  in  at 
least  greatly  relieving  the  patient,  is  a  modification  of  Valsal- 
va's  starvation  plan.  It  consists  of  perfect  rest  in  the  recum- 
bent position,  with  moderate  diet. 

The  other  method  consists  of  the  use  of  large  doses  of  iodide 
of  potassium.  This  latter  treatment  usually  soon  relieves  the 
severe  neuralgic  pains,  and  it  possesses  the  advantage  of 
allowing  the  patient  to  be  about.  The  remedy  should  be 
given  in  doses  of  ten  to  thirty  grains  three  times  a  day.  The 
larger  dose  is  much  the  best.  Coryza  may  be  relieved  by 
moderate  doses  of  nux  vomica.  If  the  stomach  becomes  irri- 
table, the  medicine  should  be  suspended  for  a  few  days.  It 
will  sometimes  be  found  that  patients  will  bear  large  doses 
who  cannot  tolerate  small  ones. 


COARCTATION  OF  THE  AORTA. 

Synonyms. — Narrowing  or  stenosis  of  the  aorta. 
This  is  one  of  the  very  rare  affections  of  the   circulatory 
system.     The  constriction  may  be  ring-like,  as  though  a  cord 


COARCTATION  OF  THE  AORTA.  351 

had  been  tied  about  the  artery ;  it  may  consist  of  a  cicatricial 
band,  partially  obstructing  the  calibre  of  the  blood-vessel ;  or 
it  may  be  due  to  irregular  contraction  of  the  artery,  the  result 
of  inflammation.  The  narrowing  of  the  vessel  may  be  slight, 
or  the  aorta  may  have  dwindled  to  an  impervious  cord.  In  a 
few  instances  the  constriction  has  been  found  to  be  general, 
involving  both  the  arch  and  the  descending  aorta.  In  such 
cases  usually  no  symptoms  have  been  observed  until  about  the 
age  of  puberty,  when  deficient  development  of  the  lower 
extremities,  and  especially  of  the  sexual  organs,  has  been  the 
first  indication  of  the  condition. 

SIGNS. 

INSPECTION. — This  affection  is  accompanied  by  signs  of 
hypertrophy  and  more  or  less  dilatation  of  the  heart.  It  is 
usually  attended  by  dilatation  of  the  arch  of  the  aorta,  of  the 
subclavian  arteries,  and  of  the  carotids  ;  and  by  a  dilated  and 
tortuous  condition  of  the  superficial  arteries,  which  in  the 
normal  state  are  not  visible.  This  condition  of  the  superficial 
arteries  is  attended  by  marked  pulsation,  and  sometimes  by 
small  aneurismal  enlargements  of  the  intercostal  arteries  which 
may  be  sufficient  to  cause  erosion  of  the  ribs. 

PALPATION.— A  thrill  can  generally  be  detected  by  palpa- 
tion over  the  large  arteries.  The  obstruction  of  the  vessel 
renders  the  pulsation  feeble  in  the  branches  of  the  abdominal 
aorta,  and  causes  feebleness  or  absence  of  the  pulse  in  the 
tibial  and  popliteal  arteries. 

PERCUSSION. — No  signs. 

AUSCULTATION. — A  harsh,  high-pitched,  and  usually  intense 
systolic  or  post-systolic  murmur  will  be  heard  over  the  aorta 
and  larger  blood-vessels.  This  is  usually  most  intense  close  to 
the  edge  of  the  sternum  in  the  second  intercostal  space  upon 
the  right  side.  This  murmur  is  propagated  through  the  carot- 
ids and  subclavians  toward  the  shoulder,  and  it  may  also  be 
heard  posteriorly  over  the  course  of  the  aorta. 

The  occurrence  of  such  a  murmur  will  lead  us  to  suspect 
the  existence  of  an  aneurism ;  but  the  latter  may  be  excluded 
by  absence  of  the  symptoms  and  signs  due  to  pressure,  and  by 
the  want  of  an  increased  area  of  dulness  on  percussion. 


t-H\ 


252 


THE   HEART   AND   AORTA. 


DIAGNOSIS. 

The  diagnosis  of  coarctation  of  the  aorta  rests  mainly  upon, 
the  enlarged  and  tortuous  condition  of  the  superficial  arteries 
in  the  upper  portion  of  the  body,  and  the  feeble  pulsation  in 
the  lower  extremities  associated  witfc  an  aortic  systolic  mur- 
mur. 

TREATMENT. 

No  treatment  can  be  recommended. 


SOLID   INTRATHORACIC  TUMORS. 

Excluding  aneurisms,  tumors  within  the  chest  are  nearly 
always  malignant  in  character,  and  are  therefore  attended  with 
grave  constitutional  symptoms. 

SYMPTOMS. 

These  growths  usually  cause  pain  of  a  persistent  character,, 
sometimes  lancinating,  but  not  subject  to  the  neuralgic  parox- 
ysms which  attend  aneurisms. 

SIGNS. 

The  principal  signs  are:  turgescence  of  the.  veins,  oedema,, 
dyspnoea,  dysphagia,  and  other  evidences  of  pressure  on  sur- 
rounding organs,  with  dulness  and  loss  of  respiratory  murmurs 
over  the  growth. 

INSPECTION. — These  growths  are  likely  to  cause  persistent 
turgescence  of  the  veins,  and  oedema  of  the  neck  and  upper 
extremities  in  a  more  marked  degree  than  aneurisms.  They 
are  nearly  always  accompanied  by  enlargement  of  the  lym- 
phatic glands  in  the  neck  and  axillary  regions.  The  condition 
of  these  glands  is  an  important  point  in  the  differential  diag- 
nosis ;  for,  if  it  is  due  to  malignant  disease,  they  will  be  adhe- 
rent to  the  surrounding  tissues,  but  if  not,  they  may  be 
moved  freely  beneath  the  integument.  The  symptoms  and 
signs  caused  by  pressure  on  the  surrounding  organs  are  per- 
sistent, and  they  gradually  increase  in  severity.  Malignant 
tumors  are  not  usually  confined  to  the  course  of  the  aorta,  but 
they  are  apt  to  extend  a  considerable  distance  beyond  the 
borders  of  the  sternum.  A  solid  tumor  does  not  ordinarily 


t- 


SOLID   INTRATORACIC   TUMORS.  253 

pulsate,  and  when  it  does  the  pulsation  is  not  expansile  but  is 
simply  lifting.  This  impulse  is  caused  by  the  pulsation  of  a 
large  artery  upon  which  the  tumor  rests. 

PERCUSSION. — The  sense  of  resistance  is  marked,  and  the 
area  of  dulness  is  usually  much  larger  than  over  aneurisms, 
because  the  malignant  disease  gradually  involves  the  adjacent 
lungs,  instead  of  crowding  them  before  it. 

AUSCULTATION. — No  bruit  can  be  heard  over  the  tumor, 
unless  it  presses  upon  an  artery,  and  then  the  murmur  is  dis- 
tant and  comparatively  feeble. 

Exceptional. — In  those  unique  cases,  where  a  tumor  co-exists  with  a  quiescent 
aneurism,  some  peculiar  phenomena  have  been  observed.  The  sense  of  resistance  to 
the  percussion  stroke  over  the  aneurism  may  be  great  ;  whereas  over  the  solid  tumor 
there  may  be  only  slight  resistance,  and  in  the  same  position  we  may  detect  an  expan- 
sile pulsation,  which  should  naturally  be  found  over  the  aneurism. 

DIFFERENTIAL   DIAGNOSIS. 

The  essential  features  which  enable  us  to  distinguish  between 
solid  tumors  within  the  chest  and  aneurisms  were  given  in  the 
beginning  of  this  lecture  when  speaking  of  the  latter  (page 

247). 

TREATMENT. 

No  special  treatment  can  be  recommended. 


DISEASES  OF  THE  THROAT 
AND  NASAL  CAVITIES. 


LECTURE    XXIII. 

EXAMINATION   OF  THE  FAUCES,  AND  LARYN- 

GOSCOPY. 

A  course  of  lectures  upon  the  physical  diagnosis  of  diseases, 
of  the  chest  would  be  incomplete,  without  a  consideration  of 
the  instruments  and  methods  which  are  employed  for  detect- 
ing diseases  in  the  larynx  and  nasal  cavities.  As  diseases  of 
the  fauces  often  cause  symptoms  which  simulate  those  of 
pulmonary  affections,  they  too  must  come  in  for"  a  share  of 
our  consideration. 

In  some  instances,  so  slight  a  difficulty  as  elongation  of  the 
uvula  will  cause  the  symptoms  of  laryngitis,  or  even  the  per- 
sistent cough,  emaciation,  and  other  symptoms  of  the  later  stage 
of  phthisis. 

EXAMINATION  OF  THE  FAUCES. 

For  the  examination  of  the  fauces  we  generally  find  it 
necessary  to  depress  the  tongue.  For  this  purpose  a  great 
variety  of  tongue  depressors  have  been  devised.  These  will  be 
found  useful,  but  if  not  at  hand,  a  lead-pencil  or  the  forefinger 
will  answer  the  purpose. 

For  ordinary  use,  a  spoon-handle  is  perhaps  the  best,  as  many 
patients  object  to  an  instrument  which  is  used  promiscuously. 
Of  the  different  varieties  of  tongue  depressors,  those  which  are 
jointed,  so  that  they  can  be  carried  in  the  pocket,  are  most 
convenient  (Fig.  46).  For  office  use,  some  of  the  larger, 


EXAMINATION   OF   THE   FAUCES. 


255 


stronger  varieties  will  be  found  more  convenient  (Fig.  45). 
Some  patients  can  depress  the  base  of  the  tongue  in  such  a 
way  as  to  allow  a  view  of  the  throat,  without  the  aid  of  any 
instrument,  but  this  is  not  the  rule.  In  children,  a  fair  view 
may  often  be  obtained  while  they  are  crying  or  coughing.  If 
the  child  resists,  and  neither  of  these  methods  succeeds,  a 


FlG- 


FIG.  44-  FIG.  45- 

FIG.  44.  —  Tuerck's  tongue  depressor,  £  size. 
FlG.  45.—  Hard-rubber  tongue  depressor,  J  size. 
FlG.  46.  —  Folding  tongue  depressor,  £  size. 

spoon-handle  or  some  other  depressor  should  be  passed  we! 
back  upon  the  base  of  the  tongue,  so  as  to  induce  retching, 
which  will  afford  a  good  view  of  the  pharynx.     You  shot 
embrace  every  opportunity  for  inspecting  the  healthy  t       at, 
in  order  to  become  familiar  with  its  normal  conditions,  other- 
wise  you  will  be  unable  to  recognize  the  signs  of  disease. 


2 eg  THE   TRHOAT   AND   NASAL    CAVITIES. 

THE  FAUCES  IN  HEALTH. — Upon  inspection  of  the  fauces, 
we  first  notice  the  soft  palate  with  the  pendent  uvula,  which 
forms  the  back  part  of  the  roof  of  the  mouth.  Running  down- 
ward from  either  side  of  the  soft  palate  will  be  seen  two  folds 
of  mucous  membrane,  known  as  the  anterior  and  posterior 
pillars  of  the  fauces,  between  which  may  be  seen  a  glandular 
mass,  which  is  termed  the  tonsil.  Posteriorly  we  observe  the 
posterior  pharyngeal  wall,  which  closely  covers  the  bodies  of 
the  cervical  vertebras. 

Superiorly,  our  field  of  vision  is  obstructed  by  the  palate ; 
and  inferiorly,  by  the  base  of  the  tongue.  In  order  to  pass 
beyond  these  in  our  inspection,  we  must  employ  the  rhinoscope 
and  the  larynsgocope. 


LARYNGOSCOPY. 

HISTORY. — The  credit  of  having  discovered  the  art  of  laryn- 
goscopy  is  usually  given  to  Czermak,  of  Pesth,  but  many 
before  his  time  had  experimented  more  or  less  successfully  in 
illuminating  the  larynx.  Bozzini  in  the  beginning  of  the  pres- 
ent century,  Bennatti  in  1832,  and  Avery,  of  London,  in  1844, 
attempted  to  illuminate  the  larynx  by  means  of  artificial  light 
conducted  through  tubes ;  but,  as  has  been  shown  by  Trous- 
seau and  Belloc,  these  instruments  crowded  the  tongue  and 
epiglottis  before  them,  so  as  nearly  or  quite  to  close  the  orifice 
of  the  larynx.  At  most,  they  could  expose  only  a  small  portion 
of  the  posterior  wall  of  the  larynx. 

About  a  hundred  years  previous  to  these  efforts,  Levret,  of 
Paris,  who  was  probably  the  first  experimenter  in  this  direc- 
tion, attempted  to  obtain  a  view  of  the  larynx  by  means  of  a 
small  throat  mirror,  similar  to  that  now  in  use.  Senn,  of 
Geneva,  in  1827;  Babbington,  of  London,  in  1829;  Baumes,  of 
Lyons,  in  1838  ;  and  Liston,  of  London,  in  1840,  employed  simi- 
lar instruments  with  equally  unsatisfactory  results.  Warden, 
in  1844,  made  experiments  with  a  couple  of  prisms.  All  of 
these  experimenters  failed  more  or  less  completely,  for  the 
reason  that  they  could  not  secure  suitable  illumination. 

The  first  to  demonstrate  the  larynx  in  the  living  subject  was 
Signor  Manuel  Garcia,  a  teacher  of  vocal  music  in  London. 


THE   LARYNGOSCOPE. 

He  became  quite  expert  in  auto-laryngoscopy,  and  also  sue- 
ceeded  in  demonstrating  the  larynx  in  others. 

Garcia's  observations  were  communicated  to  the  Royal  Soci- 
ety of  London  in  1855.     They  attracted  little  attention  at  first, 
for  the  art  was  thought  to  be  of  no  practical  value  in  the 
diagnosis  of  disease,  because  a  thorough  inspection  was  sup- 
posed to  depend  upon  a  peculiar  education  of  the  muscles 
which  would  enable  the  patient  to  control  the  position  and 
movements  of  his  throat.     However,  Garcia's  writings  induced 
Tiirck,  of  Vienna,  to  experiment  with  similar  mirrors  in  the 
hospital  during  the  summer  of  1857.     Although  Tiirck  was  not 
very  successful  in  these  experiments,  and  finally  threw  aside 
his  mirrors  as  the  autumn  came  on,  because  of  the  difficulty  in 
obtaining  sunlight,  his  experiments  were  not  lost.     Czermak, 
of  Pesth,  who  had  been  visiting  in  Vienna  during  the  summer* 
borrowed  the  mirrors  and  continued  the  investigations.     He 
overcame  the  difficulties  which  had  previously  prevented  a 
clear  view  of  the  larynx,  by  employing  the  reflector  and  caus- 
ing the  patient  to  protrude  the  tongue,  instead  of  depressing 
it,  and  by  substituting  artificial  light  for  the  direct  rays  of  the 
sun.     Soon  a  rivalry  sprang  up  between  Czermak  and  Tiirck 
as  to  the  priority  of  their  claims.     Their  letters,  which  were 
published  in  the  various  medical  journals,  soon  spread  a  knowl- 
edge of  the  new  art  throughout  the  medical  world. 


THE  LARYNGOSCOPE. 

The  essentials  for  an  examination  of  the  larynx  are  a  throat 
mirror  and  a  good  light. 

THROAT  MIRRORS  have  been  made  of  various  forms.  Some 
are  round,  others  oval  or  lozenge-shaped,  and  still  others  quad- 
rilateral. For  general  use  I  prefer  the  round  mirrors,  varying 
in  diameter  from  three  eighths  of  an  inch  to  an  inch  and  a 
quarter.  I  think  these  can  be  used  with  less  difficulty  by 
students  than  instruments  of  other  forms.  These  mirrors 
should  be  made  of  clear  and  perfectly  white  glass.  The  qual- 
ity of  the  glass  may  be  tested  by  placing  a  white  card  before 
the  mirror.  If  the  glass  is  perfectly  white,  the  reflection  will 
also  be  white ;  if  the  glass  is  tinged  with  color,  it  will  give  a 
17 


258 


THE   THROAT   AND   NASAL   CAVITIES. 


corresponding-  shade  to  the  reflected  image  of  the  card,  and  it 
would  necessarily  similarly  affect  the  laryngeal  image. 

The  glass  and  its  setting  should  Be  thin,  in  order  to  econo- 
mize space  in  the  throat. 

The  glass  should  be  set  firmly  in  a  metallic  frame,  which 
must  encroach  as  little  as  possible  upon  the  anterior  surface  of 
the  glass,  so  that  the  largest  possible  reflecting  surface  may  be 
secured.  Some  of  these  mirrors  are  backed  with  amalgam,  and 


FlG.  47. — Throat  mirrors  for  laryngoscopy.     I.  a,  handle;  b,  stem;  c,  mirror.     2. 
Different  sizes  of  round  mirrors.     3.  a,  b,  c,  different  forms  of  throat  mirrors. 

others  with  silver  leaf.  Silver  leaf  renders  a  mirror  more 
durable,  as  it  is  less  affected  by  heat  and  moisture.  I  have  used 
mirrors  backed  with  amalgam  daily  for  several  months  with- 
out injuring  them,  but  others  have  been  ruined  in  a  week. 
Therefore,  although  the  silver  leaf  does  not  give  quite  so  clear 
an  image  as  the  amalgam  when  perfect,  and  though  it  is  a 
trifle  more  expensive,  I  advise  you  to  purchase  mirrors  made 
with  it,  instead  of  those  backed  with  amalgam.  The  mirror 
should  be  firmly  attached  to  a  wire  stem  about  four  inches  in 
length,  at  an  angle  of  not  less  than  one  hundred  and  twenty 
degrees.  This  stem  may  be  fixed  in  a  small  handle  about  three 


THE   LARYNGOSCOPE. 

inches  long,  or  the  handle  may  be  removable,  the  stem  when 
inserted  being  held  by  a  set-screw.  Some  laryngologists 
recommend  a  flexible  stem,  so  that  the  angle  of  the  mirror  can 
be  easily  altered;  but  this  is  objectionable,  as  it  is  likely  to 
become  bent  by  contraction  of  the  palatine  muscles  when  the 
mirror  is  in  position,  in  such  a  manner  that  the  larynx  cannot 
be  seen. 

An  inflexible  stem  is  always  preferable,  for  the  obliquity  of 
the  mirror  can  be  easily  altered  by  elevating  or  lowering  the 
handle.  Again,  it  is  better  for  the  beginner  to  attribute  want 
of  success  to  lack  of  skill  rather  than  to  a  defect  in  the  mirror. 
If  the  beginner  attempts  to  alter  the.obliquity  of  the  mirror  by 
bending  the  stem,  he  is  likely  to  break  the  instrument  in  his 
frequent  attempts  to  secure  an  angle  which  will  give  a  different 
view  of  the  larynx. 

THE  LIGHT. — To  obtain  a  perfect  illumination  of  the  larynx 
three  things  are  necessary.  First,  the  eye  should  be  brought 
as  nearly  as  possible  into  the  centre  of  the  beam  of  light  used 
in  the  illumination  ;  second,  a  bright  light  is  needed  ;  and  third, 
the  focal  point,  when  convergent  rays  are  used,  should  fall 
upon  the  part  to  be  inspected. 

By  such  a  position  of  the  eye,  the  most  distinct  image  is 
obtained.  A  good  light  is  needed,  and  it  must  be  very  bright 
if  a  small  throat  mirror  is  used,  for  the  smaller  the  mirror  the 
fewer  the  rays  which  can  be  reflected  from  it ;  consequently  we 
must  make  up  in  intensity  what  is  lost  in  volume. 

All  forms  of  illumination  which  cast  convergent  rays  into 
the  larynx  cause  above  and  below  the  focal  point,  what  are 
known  as  circles  of  dispersion,  in  which  the  illumination  for  a 
short  distance  is  nearly  as  bright  as  at  the  focal  point.  In  ex- 
amining the  larynx,  an  effort  should  be  made  to  concentrate  the 
rays  of  light  on  the  vocal  cords,  and  then  the  circles  of  disper- 
sion will  give  a  good  illumination  for  half  an  inch  above  or 
below  the  plane  of  the  glottis.  In  adult  males,  the  glottis  is 
about  three  inches  below  the  mirror  when  it  is  held  in  the 
posterior  part  of  the  mouth,  and  in  this  position  the  mirror  is 
about  three  inches  from  the  lips,  therefore  the  glottis  is  about 
six  inches  within  the  lips,  or  in  females  about  five  inches.  As 
the  eye  cannot  be  brought  nearer  to  the  mouth  than  five  me 
without  interfering  with  the  manipulation  of  the  instrument, 


26o  THE   THROAT   AND   NASAL   CAVITIES. 

the  radiant  or  focal  point  must  fall  eleven  inches  from  the 
reflector,  which  is  worn  on  the  forehead. 

Being  myself  hypermetropic,  I  find  it  most  convenient  to 
have  my  eye  at  least  eight  inches  from  the  patient's  mouth  ; 
therefore  I  must  use  a  reflector  which  will  concentrate  the  rays 
of  light  at  a  point  fourteen  inches  from  itself. 

Persons  with  presbyopic  eyes  may  obtain  a  good  view  in 
the  same  manner,  or  deficient  accommodation  in  the  eye  may 
be  corrected  by  glasses. 

Myopic  eyes  of  less  than  one  tenth  will  necessitate  the  use 
of  concave  glasses ;  but  when  from  one  tenth  to  one  seventeenth, 
glasses  will  not  be  needed,  excepting  to  view  the  bifurcation  of 
the  trachea. 

When  we  wish  to  examine  the  bifurcation  of  the  trachea, 
which  is  five  or  six  inches  below  the  plane  of  the  vocal  cords, 
we  must  remember  that  the  focal  point  should  be  at  least  six- 
teen or  seventeen  inches  distant  from  the  reflector. 

MANAGEMENT  OF  THE  LIGHT. — The  larynx  may  be  illumi- 
nated by  a  simple  flame,  or  a  concave  reflector  with  or  without 
condensing  lenses  may  be  employed  to  reflect  the  rays  of  light 
into  the  throat.  In  illuminating  the  larynx  by  the  direct  rays 
of  the  sun,  lenses  are  not  used,  and  reflectors  are  not  absolutely 
necessary.  When  diffused  daylight  is  employed,  reflectors  are 
required  to  concentrate  the  rays.  Though  direct  sunlight,  or 
sometimes  diffused  daylight,  gives  a  beautiful  illumination,  arti- 
ficial light  will  be  found  indispensable  for  general  use.  Natural 
light  cannot  usually  be  secured  in  the  proper  position  at  the 
time  we  wish  to  use  it. 

Direct  illumination  with  artificial  light.- — When  using  a  simple 
flame  without  a  reflector,  the  lamp  must  be  placed  directly  in 
front  of  the  patient's  mouth,  and  shaded  toward  the  eye  of  the 
observer.  This  will  give  a  good  illumination  if  the  light  is  very 
bright,  but  with  the  ordinary  lamp*  or  gas-jet,  it  is  not  satisfac- 
tory. Such  a  method  of  illumination  may  be  improved  by  using 
a  condensing  lens  with  a  focal  distance  of  six  or  seven  inches. 
The  lens  having  been  warmed,  to  prevent  the  vapor  in  the 
breath  from  condensing  on  it,  should  be  held  between  the  light 
and  the  patient's  mouth,  and  about  five  inches  from  the  latter. 
The  flame  should  be  placed  at  a  point  which  will  cause  its  rays 
to  be  brought  to  a  focus  eleven  inches  beyond  the  lens  on  the 


THE    LARYNGOSCOPE.  26l 

plane  of  the  glottis.     The  observer's  eye  must  then  be  brought 
near  the  edge  of  the  lens. 

Illumination  with  reflected  artificial  light. — This  same  apparatus 
may  be  supplemented  by  a  plane  perforated  reflector  which  is 
placed  in  front  of  the  observer's  eye,  the  rays  proceeding  from 
the  lens  being  thrown  upon  it,  and  thence  reflected  into  the 
mouth.  Or  this  reflector  may  be  used  with  the  simple  flame 
without  the  intervention  of  a  condenser. 

Concave  reflectors. — In  order  to  fulfill  the  three  essential  condi- 
tions, that  is,  to  have  the  eye  in  the  centre  of  the  cone  of  light, 
to  obtain  a  bright  illumination,  and  to  have  the  focal  point  fall 
upon  the  part  to  be  examined,  laryngologists  generally  resort 
to  perforated  concave  reflectors.  This  mirror  collects  many 
rays  which  would  otherwise  be  lost,  and  concentrates  them  on 
the  point  to  be  examined,  thus  intensifying  the  illumination,  and 
in  consequence  of  the  perforation  in  its  centre,  the  observer's 
eye  may  be  brought  into  the  centre  of  the  cone  of  light.  Many 
laryngologists  prefer  to  place  the  reflector  above  the  eye,  but 
unless  a  very  bright  light  is  employed,  this  position  will  not 
give  a  good  illumination  of  the  larynx,  and  if  a  brilliant  light  is 
used,  it  is  very  trying  to  the  eyes. 

The  advantages  of  a  perforated  reflector  are,  other  things 
being  equal,  that  it  gives  the  best  possible  illumination  and  it 
protects  the  observer's  eyes  from  the  glare  of  the  flame. 

These  reflectors  vary  in  size  and  in  focal  distance,  also  in  the 
material  of  which  they  are  constructed.     Those  used  in  laryn- 
goscopy  are  usually  from  three  to  four  inches  in  diameter,  with 
a  focal  distance  ranging  from  five  or  six  to  fourteen  or  sixteen 
inches.     They  are  made  either  of  glass  or  of  metal ;  those  made 
of  glass  are  best,  as  the  metallic  reflectors  soon  become  dim. 
For  ordinary  use,  a  reflector  with  a  focal  distance  of  seven  or 
eight  inches  will    give  better   satisfaction    than    one  wit 
longer  focus,  except  when  parallel  rays  of  light  as  those  of  tb 
sun  or  of  diffused  daylight,  are  to  be  reflected.     The  rays  co 
ing  from  any  artificial  light  are  necessarily  divergent,  am 
sequently  they  cannot  be  brought  to  a  focus  in  the  larynx,  by 
a  reflector  with  a  focal  distance  of  eleven  inches,  which  woi 
concentrate  parallel  rays  at  the  proper  point. 

With  the  ordinary  position  of  the  flame,  and  of  the  c 
eve,  a  reflector  of  seven  inches  focal  distance  will  throw  the 


THE   THROAT   AND   NASAL  CAVITIES. 

radiant  point  upon  the  glottis.  The  radiant  point  may  readily 
be  moved  toward  and  from  the  eye  by  increasing  or  lessening 
the  distance  of  the  flame  from  the  reflector,  so  that  mirrors  of 
varying  focal  distances  may  be  employed,  providing  the  light 
is  sufficiently  intense. 

To  make  this  matter  clearer,  I  ask  your  attention  to  the  fol- 
lowing formula. 

ill 
T~  A~+A7* 

On  account  of  its  simplicity,  this  formula  has  been  generally 
adopted  in  determining  the  focal  distance  of  the  reflector,  or 
the  proper  position  of  the  flame,  which,  with  a  reflector  of 
a  known  focal  distance,  will  cause  the  image  of  the  flame  to 
fall  upon  the  glottis.  The  image  of  the  flame  and  the  radiant 
point  are  in  this  connection  used  as  synonymous  terms.  The 
focal  point  is  the  same  as  the  radiant  point,  when  parallel  rays 
of  light  are  employed. 

In  this  formula  "  F "  represents  the  focal  distance  of  the 
reflector;  "  A "  represents  the  distance  of  the  reflector  from 
the  flame  ;  "  A' "  represents  the  distance  of  the  reflected  image 
of  the  flame  (focal  or  radiant  point)  from  the  reflector.  For  ex- 
ample, knowing  the  focal  distance  oi  the  reflector,  which  is 
seven  inches,  and  the  proper  distance  of  the  image  of  the  flame, 
which,  as  I  have  already  explained,  must  fall  upon  the  glottis, 
and  will  therefore  be  eleven  inches  from  the  reflector — five 
inches  from  the  observer's  eye  to  the  patient's  mouth,  and  six 
inches  from  the  patient's  lips  to  his  vocal  cords — we  can  readily 
ascertain  the  proper  position  of  the  flame  by  placing  the  known 
quantities  in  the  formula  thus  %  =  l  +  TV  This  reduced  will 
give  a  fraction  over  nineteen  inches  as  the  value  of  "  A ;  "  which 
will  represent  the  proper  distance  of  the  flame  from  the 
reflector. 

If  we  wish  to  find  the  focal  distance  of  the  reflector  by  arti- 
ficial light,  we  proceed  in  a  similar  manner  with  the  same 
formula.  Placing  the  light  at  a  fixed  point  and  the  reflector  in 
front  of  it,  we  find  the  distances  from  the  flame  to  the  reflector, 
and  from  the  reflector  to  the  image  of  the  flame,  by  direct 
measurement  with  an  ordinary  tape.  These  two  known  quan- 
tities being  then  inserted  in  the  formula  in  the  place  of  A  and 
A',  the  value  of  F  can  readily  be  obtained.  The  focal  distance 
of  a  reflector  may  be  easily  ascertained  with  solar  light,  by 


THE   LARYNGOSCOPE.  2(5 

placing  it  in  the  sunlight,  throwing  the  radiant  point  on  some 
object,  and  then  measuring  the  distance  from  the  centre  of  the 
reflector  to  the  focal  point.  The  focal  distance  may  be 
measured  with  diffused  light,  by  reflecting  the  image  of  some 
distant  object,  as  a  window,  on  some  plane  surface,  and  measur- 
ing the  distance  from  this  image  to  the  reflector. 

In  using  reflectors,  the  essential  thing  to  be  remembered  is 
that  the  light  must  be  so  managed  that  the  radiant  point  will 
fall  on  the  part  to  be  illuminated. 

Met  hod  of  illuminating  the  larynx  by  the  aid  of  a  concave  reflector. 
—Students  of  laryngoscopy  usually  have  great  difficulty  in 
obtaining  a  uniform  illumination.  Sometimes  the  parts  will  be 
brilliantly  illuminated,  at  other  times  with  the  same  light  and 
the  same  laryngoscope  the  larynx  is  only  seen  in  a  deep 
shadow.  This  is  generally  due  to  the  improper  position  of  the 
light.  You  must  not  forget  that  the  larynx  is  necessarily  from 
eleven  to  fourteen  inches  from  the  eye,  and  that,  with  a 
reflector  of  seven  or  eight  inches  focal  distance,  if  the  flame  be 
placed  too  near  the  eye,  the  radiant  point  will  fall  a  consider- 
able distance  beyond  the  glottis ;  or  if  the  flame  be  placed  too 
far  from  the  eye,  the  radiant  point  will  not  reach  the  glottis. 
You  should  always  know  the  focal  distance  of  your  reflector ; 
you  should  ascertain  by  the  formula  (page  262)  the  proper  dis- 
tance at  which  to  place  the  flame  ;  and  you  must  remember  that 
the  distance  of  the  radiant  point  from  the  reflector  will  vary 
as  the  latter  is  carried  toward  or  from  the  flame. 

Practically,  if  you  have  a  proper  reflector  of  seven  to  eight 
inches  focal  distance,  it  will  not  be  necessary  to  measure  accu- 
rately the  distance  of  the  flame  ;  but  placing  your  light  beside 
the  patient,  seat  yourself  in  front  with  your  reflector — worn 
upon  the  forehead  or  before  the  eye — ten  or  eleven  inches  in 
front  of  the  patient's  mouth.  Now  carry  the  light  forward  or 
backward  until  its  perfect  inverted  image  falls  on  the  patient's 
lips,  and  there  leave  it.  Then  bring  your  reflector  about  four 
inches  nearer  the  mouth,  and  the  radiant  point  will  fall  upon 
the  glottis. 

Means  for  holding  the  reflector.— Various  contrivances  are 
employed  for  holding  the  reflector.  Czermak  at  first  had  it 
fastened  to  a  mouth-piece  of  orris-root  which  he  held  between 
his  teeth.  Semeleder  and  others  are  in  favor  of  spectacle 


264 


THE   THROAT   AND   NASAL   CAVITIES. 


frames,  to  which  the  reflector  is  so  fastened  that  it  may  rotate 
in  any  direction.  If  the  physician  happen  to  be  myopic  or 
hypermetropic,  lenses  may  be  fitted  in  the  frames  so  as  to 
correct  the  error  in  accommodation.  Jointed  arms-for  holding 
ths  reflector  accompany  many  forms  of  illuminating  apparatus 
(Fig.  52,  page  267).  These  are  inconvenient  if  the  patient 
moves  after  the  arm  has  been  adjusted,  for  each  movement  of 
the  patient  may  require  a  change  in  the  position  of  the  reflec- 
tor. Kramer's  head  band,  or  some  modification  of  it,  is  the 
most  common,  and,  I  think,  the  best  device  for  holding  the 
reflector.  This  consists  of  a  head  band  with  a  metallic  or  vul- 
canite plate  in  front  to  which  the  reflector  is  attached  by  a 
ball  and  socket  joint,  which  enables  us  to  fix  it  in  any  position. 
Most  of  the  head  bands  are  open  to  two  objections ;  first,  they 
cannot  be  made  tight  enough  to  hold  the  reflector  firmly  with- 
out causing  headache ;  and  second,  the  ball  and  socket  joint  is 


FlG.  48. — Schroetter's  head  band  with  nasal  rest. 

so  constructed  that,  after  it  becomes  a  little  worn,  it  is  impos- 
sible to  fix  the  reflector  firmly.  Schroetter's  head  band,  with 
nasal  rest,  obviates  these  difficulties  very  completely.  I  have 
had  an  arm  constructed  with  an  extra  joint  which  affords  a 
point  for  the  attachment  of  a  plane  mirror  in  addition  to  the 
reflector.  This  enables  me  to  inspect  the  larynx  through  the 
aperture  in  the  concave  reflector,  while  persons  standing 
near  can  see  the  same  image  in  the  plane  mirror. 

Whatever  the  means  employed  for  holding  the  reflector,  it 
must  be  borne  in  mind  that  the  flame  must  have  a  certain  defi- 
nite relation  to  the  reflector,  depending  on  the  focal  distance 
of  the  latter  and  its  distance  from  the  glottis,  so  that  the  image 
of  the  flame  will  fall  upon  the  vocal  cords. 


LECTURE    XXIV. 
LARYNGOSCOPY— Continued. 

In  place  of  throwing  the  radiant  point  on  the  glottis,  some 
physicians  prefer  to  illuminate  the  parts  to  be  examined  with 
the  bright  disk  of  light  which  may  be  obtained  in  the  circle  of 
dispersion  above  or  below  the  radiant  point. 

Several  instruments  have  been  devised  for  the  purpose  of 
rendering  the  light  in  this  disk  more  intense. 

One  of  the  simplest  of  these  is  Krisliabers  Illuminator  (Fig. 


PA 
FIG.  49.— Krishaber's  Illuminator.     A,  Lens  ;  B,  Reflector. 

49).     It  consists  of  a  reflector  and  a  convex  lens,  which  may  be 
fastened  by  the  clamp  to  an  ordinary  lamp. 

This  apparatus  will  often  give  very  satisfactory  results. 

Mackenzie's  BulVs-Eye  Condenser  is  used  for  the  same  purpose. 
This  consists  of  a  rack-movement  gas  fixture  with  a  metallic 
chimney,  which  can  be  adjusted  to  the  ordinary  gas  burner  ( 
50).     The  chimney  has  an  orifice  on  one  side  for  the  condensing 
lens,  and  the  latter  is  placed  at  a  fixed  point  in  front  of  the 


266 


THE   THROAT   AND   NASAL  CAVITIES. 


flame,  so  that  the  rays  of  light  on  leaving  it  will  be  nearly 
parallel.  This  illuminator  may  be  brought  directly  in  front  of 
the  patient's  mouth  for  direct  illumination,  but  it  is  generally 


FIG.  50. — Mackenzie's  rack-movement  bull's-eye  condenser. 

used  with  a  reflector  of  from  eleven  to  fourteen  inches  focal 
distance. 


FIG.  51. — Modification  of  Mackenzie's  illuminator  which  may  be  used  either  with  a 
student's  lamp  or  an  Argand  gas  burner. 

Fraenkei's  Illuminator  is  somewhat  similar  in  construction  as 


THE  LARYNGOSCOPE.  267 

regards  the  condensing  lens,  but  is  so  arranged  that  the  rays 
of  light  on  leaving  the  lens  may  be  made  either  divergent,  par- 
allel, or  convergent,  according  to  the  size  and  focal  distance 
of  the  reflector  which  is  employed. 

I  have  had  Messrs.  Sharp  and  Smith,  of  this  city,  construct 
a  similar  condenser,  which  may  be  used  with  the  ordinary 
Argand  gas  burner  or  German  student's  lamp  (Fig.  51).  In 
this  condenser  the  lens  is  so  set  that  the  rays  of  light  are 
divergent  on  leaving  it,  and  are  thus  adapted  for  a  reflector 
with  a  focal  distance  of  seven  or  eight  inches.  If  it  is  desired 
to  obtain  a  bright  circle  of  dispersion  for  illumination,  or  to 
use  a  reflector  with  a  longer  focal  distance,  the  cap  in  which 
the  lens  is  set  can  be  drawn  out  so  that  the  rays  will  be  less 
divergent. 


JTIG    52. — Tobold's  Illuminator. 

This  condenser  is  comparatively  inexpensive,  and  possesses 
all  the  advantages  of  the  last  two  described,  as  well  as  thos 
Tobold's  illuminator,  without  the  imperfections  of  the  latl 
With  this  condenser  and  Fraenkel's,  either  the  radiant  point , 
the  circle  of  dispersion  may  be  used  for  illuminating  the  glo 

Tobold's  Illuminator. -W*  a  view  to  >™7,thf /  "" 
ation,  a  combination  of  lenses  was  devised  by  Tobold wh 
is  in  common  use  ;  but  such  a  combmati. 

c°ntrary' weii  has    n 


268  THE   THROAT   AND    NASAL   CAVITIES. 

that  the  apparatus  is  improved  by  removing  one  or  two  of  its 
lenses.  These  lenses  merely  cause  a  large  circle  of  dispersion, 
which,  though  very  handsome  when  thrown  on  an  external 
object,  is  in  point  of  fact  less  intense  than  the  image  of  the 
the  flame. 

Tobold's  apparatus  has  a  combination  of  three  lenses,  two  of 
which,  each  having  a  focal  distance  of  about  three  inches,  are 
placed  closely  together,  and  so  near  the  flame  that  they 
collect  divergent  rays  as  they  leave  the  lamp,  and  concentrate 
them  to  a  focus  about  six  inches  in  front  of  the  second  lens. 
The  third  lens,  which  is  farthest  from  the  flame,  has  a  focal 
distance  of  about  five  inches.  It  is  placed  four  inches  in  front 
of  the  second  lens,  about  two  inches  within  the  point  at  which 
the  rays  of  light  are  concentrated  by  the  latter,  so  that  the  rays 
of  light  falling  on  it  are  convergent.  The  convergent  rays 
falling  upon  the  third  lens,  by  passing  through  it,  are  rendered 
still  more  convergent  and  are  brought  to  a  focus  about  three 
inches  in  front  of  the  apparatus  where  the  image  of  the  flame 
is  perfect  The  reflector  is  fixed  about  four  inches  in  front  of 
the  apparatus,  or  one  inch  beyond  the  radiant  point  of  the  last 
lens.  Here,  the  rays  having  crossed,  are  so  widely  diver- 
gent, that  a  reflector  of  one  and  a  half  inches  focal  dis- 
tance would  be  required  to  concentrate  them  upon  the  glottis. 
The  reflector  used  has  a  focal  distance  varying  in  different 
instruments  which  I  have  examined,  from  five  to  nine  inches. 
Therefore  the  rays  must  also  leave  the  reflector  widely  diver- 
gent, so  that  most  of  them  will  be  lost.  Hence  we  see  that  the 
large  bundle  of  rays  collected  by  the  first  lens,  which  might 
then  have  been  entirely  utilized,  is  first  subjected  to  the  loss 
incident  to  refraction,  and  is  then  largely  thrown  away.  Yet 
we  must  admit  that  a  sufficient  number  of  rays  are  still  retained 
to  give  a  good  illumination,  though  less  intense  than  when  only 
one  lens  is  employed.  It  follows  then  that  no  possible  advan- 
tage can  be  derived  from  a  combination  of  lenses,  except  where 
cheap  lenses  of  a  moderate  convexity  are  placed  together  to 
secure  a  short  focal  distance.  A  single  lens  of  sufficiently  high 
power  to  accomplish  the  same  result  would  be  comparatively 
expensive.  Tobold  has  also  devised  a  smaller  instrument 
known  as  the  pocket  illuminator,  the  construction  of  which  is 
similar  to  that  of  the  one  just  described. 


THE   LARYNGOSCOPE.  269 

The  image  of  the  flame  may  be  so  magnified  by  a  single  lens, 
as  found  in  the  condensers  already  mentioned,  that  it  is  as 
large  as  can  possibly  be  reflected  from  any  throat  mirror. 

Use  of  condensing  lenses. — In  using  condensing  lenses,  any  one 
of  three  methods  may  be  adopted.  First,  the  flame  may  be 
placed  at  the  focal  point  of  the  lens ;  second,  it  may  be  placed 
beyond  the  focal  point ;  or  third,  it  may  be  placed  nearer  to 
the  lens  than  its  focal  point. 

With  the  flame  at  the  focal  point,  the  rays  which  always 
leave  the  light  in  a  divergent  direction  are  refracted,  so  as  to 
leave  the  lens  in  a  parallel  direction,  and  they  must  then  be 
managed  in  the  same  manner  as  the  parallel  rays  of  sunlight  or 
diffused  daylight.  In  this  instance,  in  order  to  lose  none  of  the 
light,  a  reflector  of  a  diameter  the  same  as  that  of  the  lens 
should  be  employed,  and  it  should  have  a  focal  distance  of  from 
eleven  to  fourteen  inches.  This  will  bring  the  image  of  the 
flame  upon  the  glottis,  providing  the  eye  is  from  five  to  eight 
inches  from  the  mouth. 

When  the  flarrie  is  placed  beyond  the  focal  distance  of  the 
lens,  its  divergent  rays,  after  passing  through  the  lens,  become 
convergent.  In  this  case,  the  reflector  may  be  smaller  than 
the  lens,  but  you  will  readily  understand  that  it  must  have 
a  focal  distance  of  more  than  eleven  or  fourteen  inches;  other- 
wise the  rays  will  be  brought  to  a  focus  too  soon. 

When  the  flame  is  placed  nearer  the  lens  than  its  focal  dis- 
tance, the  rays,  after  passing  through  the  lens,  are  still  diver- 
gent, and  in  order  that  none  of  them  be  lost,  they  must  be 
received  on  a  reflector  larger  than  the  lens,  and  it  must  have  a 
focal  distance  of  not  more  than  eight  inches,  or  in  other  words 
the  same  focal  distance  as  that  required  when  a  flame  is  used 
without  a  condensing  lens.  This  is  by  far  the  best  method  for 
practical  purposes,  as  it  gives  an  illumination  equally  as  good 
as  the  other  methods,  and  it  does  not  necessitate  the  possession 
of  a  number  of  reflectors. 

Some  form  of  condenser  is  desirable  for  office  use,  but  I  have 
always  found  a  simple  concave  reflector  of  large  size  and  short 
focal  distance  sufficient  for  purposes  of  diagnosis,  and  ordina- 
rily for  operations  within  the  larynx.     Such  a  reflector  may  t 
used  with  an  ordinary  gas  jet  or  with  any  lamp,  and  it  may  t 
sufficient,  even  if  we  are  obliged  to  rely  on  candles  for  our 


270  THE   THROAT  AND   NASAL   CAVITIES. 

light.     For  general  use  it  will  certainly  be  found  more  satis- 
factory than  a  cumbersome  illuminating  apparatus. 

When  performing  operations  in  the  larynx,  it  is  desirable  to 
have  as  large  a  field  illuminated  as  possible.  This  end  may  be 
attained  by  means  of  the  bull's-eye  condenser  with  the  ordinary 
flame ;  or  by  the  same  with  a  brighter  light,  and  a  reflector 
with  a  long  focal  distance,  so  that  the  circle  of  dispersion  can 
be  utilized  in  place  of  the  radiant  point. 

The  light. — The  electric  light  would  perhaps  be  the  best  for 
laryngoscopy,  and  next  to  it,  the  oxy-hydrogen  light. 

The  former,  however,  cannot  as  yet  be  readily  obtained,  and 
the  latter,  besides  being  difficult  to  manage,  requires  a  great 
deal  of  apparatus,  and  is  consequently  expensive.  A  good 
Argand  gas  burner  or  a  German  student's  lamp  with  a  bull's- 
eye  condenser  is  all  that  is  necessary  for  illumination,  even 
during  operations.  1  have  sometimes  obtained  brilliant  illu- 
mination even  with  a  common  kerosene  lamp,  having  a  round 
wick  like  that  shown  in  Fig.  49.  For  purposes  of  diagnosis, 
any  ordinary  lamp,  freshly  trimmed,  and  with  a  clean  chimney, 
will  generally  be  sufficient.  As  suggested  by  Dr.  Cohen,  two 
or  three  candles  tied  together,  and  placed  in  front  of  the  bowl 
of  a  spoon  used  as  a  reflector,  may  be  made  to  answer  the  pur- 
pose, if  a  lamp  cannot  be  obtained. 

Diffused  day-light,  when  properly  managed,  gives  a  beauti- 
ful illumination  of  the  larynx.  Artificial  light,  more  or  less, 
discolors  the  image,  causing  the  normal  larynx  to  appear  yel- 
lowish or  red,  whereas  diffused  daylight  shows  the  parts  in  their 
natural  colors.  Unfortunately  the  latter  is  seldom  sufficiently 
bright.  On  a  bright  day,  if  light  can  be  admitted  through  a 
small  opening  into  a  darkened  room  so  as  to  fall  upon  the 
reflector,  it  will  give  a  good  illumination.  If  it  is  impossible 
to  admit  the  light  through  a  small  aperture,  a  good  view  may 
sometimes  be  obtained  by  placing  the  patient  at  the  farther 
side  of  the  room,  opposite  a  single  window  left  uncovered,  with 
his  back  to  the  light.  This  position  will  give  a  much  better 
view  than  when  the  patient  is  placed  near  the  window. 

Direct  sunlight  may  be  employed  by  placing  the  patient, 
facing  the  window,  in  such  a  position  that  the  rays  will  fall 
upon  the  throat  mirror  held  in  the  pharynx.  A  serious  objec- 
tion to  this  method  is  that  the  light  cannot  often  be  obtained 


THE   LARYNGOSCOPE.  271 

in  a  suitable  position.  Reflected  sunlight  may  more  frequently 
be  employed  with  the  aid  of  a  plane  reflector,  or  of  one  with  a 
long  focal  distance.  Even  this  light  is  open  to  serious  objec- 
tion, for  it  is  only  in  comparatively  rare  instances  that  we  have 
a  proper  exposure  and  find  the  sun  at  the  desired  altitude. 

Heliostats  have  been  constructed  for  reflecting  the  sunlight 
in  a  given  direction.  They  may  be  arranged  by  a  system  of 
clock-work  so  as  to  maintain  the  beam  of  light  at  a  given  point 
throughout  the  day.  This  apparatus  is  very  expensive,  and 
therefore  I  do  not  recommend  it. 

An  ordinary  toilet  mirror  may  be  so  placed  as  to  receive  a 
beam  of  sunlight,  and  direct  it  horizontally  in  any  desired 
direction  ;  but  this  is  not  often  satisfactory,  for  the  angle  of  the 
mirror  must  be  changed  frequently,  and  a  cloud  is  liable  to 
hide  the  sun  just  as  its  light  is  most  needed.  For  these  various 
reasons  we  are  usually  compelled  to  use  artificial  light. 

You  should  practice  laryngoscopy  both  with  natural  and 
with  artificial  light,  in  order  to  become  familiar  with  the 
appearance  of  the  parts  under  both  forms  of  illumination.  The 
same  larynx  will  have  a  different  shade  when  viewed  by  the 
different  lights.  The  larynx,  which  appears  congested  when 
viewed  by  artificial  light,  may  seem  of  normal  color  by  natural 
light. 

For  the  purpose  of  magnifying  the  image  of  the  larynx,  Dr.  Wertheim  recommended 
concave  throat  mirrors,  and  Dr.  Tiirck  suggested  a  small  telescope,  some  improvements 
in  which  were  made  by  Voltolini ;  but  these  have  all  been  found  practically  useless. 

Dr.  A.  W.  Adams,  of  Colorado  Springs,  Colorado,  has 
invented  a  laryngoscope  for  which  the  source  of  light  consists 
of  a  coil  of  wire,  heated  to  incandescence  by  electricity  and 
placed  immediately  in  front  of  a  small  metallic  cap,  which  is 
attached  to  the  handle  of  the  throat  mirror.  The  instrument  is 
said  to  give  a  good  illumination.  The  laryngoscope  which  I 
prefer  consists  of  a  perforated  reflector  four  inches  in  diameter, 
with  a  focal  distance  of  seven  inches,  attached  to  Schroetter's 
head  band  with  nasal  rest  by  means  of  a  ball  and  socket  joint ; 
three  round  throat  mirrors,  three  eighths,  seven  eighths,  and 
nine  eighths  of  an  inch  in  diameter  respectively,  the  smallest 
for  children ;  and  one  oval  mirror  three  fourths  of  an  inch  in 
diameter,  for  use  in  cases  of  enlarged  tonsils.  As  before  stated 
these  throat  mirrors  should  be  backed  with  silver  leaf  and 


272  THE   THROAT  AND   NASAL   CAVITIES. 

firmly  fastened  to  an  inflexible  stem,  which  may  be  perma- 
nently fastened  to  the  handle  or  not,  as  is  most  convenient. 
The  reflector  need  not  be  more  than  three  and  one  half  inches 
in  diameter,  but  the  larger  instrument  will  reflect  a  greater 
number  of  rays,  and  thus  give  a  somewhat  brighter  illumina- 
tion. The  four-inch  reflector  possesses  the  additional  advan- 
tage, when  worn  before  one  eye,  of  shading  the  opposite  eye 
more  perfectly  from  the  flame.  The  only  objection  I  have 


I 

FIG.  53. — Adams'  electric  laryngoscope. 

A,  Spiral  vacuum  tube  containing  wire  which,  when  heated  by  the  electric  current, 
furnishes  the  light.  B,  Cap  for  glass  tube.  D,  Ball  and  socket  joint  regulated  by 
screw  I.  H,  Binding  posts  for  wire.  K,  Stem.  E,  Mirror.  F,  Ball  and  socket 
joint.  J,  Sliding  ring  to  regulate  joint  at  F.  G,  Attachment  of  illuminating  appa- 
ratus to  handle  of  mirror. 

found  to  it  is,,  that  the  attachment  for  the  ball  and  socket 
joint  is  placed  a  trifle  too  far  from  the  perforation,  which  some- 
times causes  a  little  difficulty  in  bringing  the  perforation 
squarely  before  the  eye.  However,  this  difficulty  may  be 
overcome  by  wearing  the  nose-rest  a  little  to  one  side. 
This  objection  might  be  easily  remedied  by  the  manufacturer. 
This  reflector  is  a  little  more  expensive  than  the  one  three  and 
a  half  inches  in  diameter.  For  an  illuminating  apparatus,  I 
would  recommend  an  Argand  gas  burner  attached  to  a  rack- 
movement  fixture,  similar  to  the  one  shown  (Fig.  50,  page  266) ; 
or  a  German  student's  lamp  which  ma)'  be  supplemented  when 
you  wish  by  a  condenser  (Fig.  51,  page  266). 

The  cost  of  this  outfit  is  small.  A  three  and  one  half  inch 
reflector,  five  dollars ;  a  head  band  and  nose  rest,  two  dollars 
and  a  half ;  and  five  throat  mirrors  at  a  dollar  to  a  dollar  and  a 
half  each.  It  will  be  seen  that  an  excellent  laryngoscope  need 
not  cost  more  than  fifteen  dollars.  A  German  student's  lamp, 
or  a  rack-movement  gas  fixture  with  Argand  burner,  will  cost 


THE   RHINOSCOPE. 


273 


only  five  or  six  dollars ;  a  condenser  may  be  purchased  at  a 
cost  of  from  eight  to  ten  dollars. 


THE   RHINOSCOPE. 

Rhinoscopy,  or  inspection  of  the  posterior  nares  and  the 
vault  of  the  pharynx,  is  practiced  with  the  same  instruments 
used  for  laryngoscopy,  excepting  that  smaller  throat  mirrors 
are  usually  required,  i.  e.,  those  from  half  to  five  eighths  of  an 
inch  in  diameter,  and  it  is  generally  best  to  have  a  flexible 
stem  to  the  mirror,  which  may  be  readily  bent  to  conform  to 
the  floor  of  the  mouth  (Fig.  62,  page  286). 

The  mirror  may  be  set  at  right  angles  to  the  stem,  or  at  the 
same  angle  as  the  laryngeal  mirrors.  An  angle  between  these 
two  is  sometimes  preferred,  but  the  exact  angle  is  a  matter  of 
little  importance,  as  the  obliquity  of  the  mirror  may  be  easily 


FIG.  54.— Fraenkel's  rhinoscope.     The  angle  of  the  mirror  (a)  can  be  changed  at 

will  by  moving  the  sliding  rod  at  b. 

changed  by  raising  or  lowering  the  handle.  Special  throat 
mirrors  have  been  constructed  for  rhinoscopy  (Fig.  54)  but 
they  do  not  seem  to  me  superior  to  those  already  described. 
A  tongue  depressor  will  be  often  needed  in  rhinoscopy,  and 
various  forms  of  blunt  hooks  and  other  instruments  may  be 
used  for  holding  the  uvula;  but  these  latter  are  rarely  em- 
18 


274  THE   THROAT   AND   NASAL   CAVITIES. 

ployed,  and  are  seldom,  if  ever,  of  any  use  excepting  during 
operations. 

Anterior  rhinoscopy  is  performed  with  the  aid  of  the  laryn- 
goscopic  reflector  and  a  nasal  speculum.  Various  specula  have 
been  made  for  the  purpose.  A  single  bivalve  speculum,  such  as 


FIG.  55.— Nasal  Speculum. 


is  also  used  for  the  ear,  is  as  good  as  any  for  purposes  of  diag- 
nosis ;  but  when  operations  are  to  be  performed  an  instrument 
which  will  retain  its  position,  when  placed  in  the  nostrils, 
answers  better  (Fig.  55). 

MODE   OF    USING   THE    LARYNGOSCOPE. 

The  most  favorable  position  for  a  laryngoscopic  examination 
is  with  the  patient  seated  in  an  erect  position  with  the  head 
thrown  slightly  backward.  The  physician  should  be  seated  in 
front  on  the  same  or  on  a  slightly  higher  level,  and  as  close  as 
possible,  with  one  knee  on  either  side  of  the  patient's  knees, 
which  are  brought  together. 

It  must  not  be  supposed  that  this  is  the  only  position  in  which  a  good  view  of  the 
larynx  can  be  obtained  It  is  often  necessary  to  make  the  examination  with  the  patient 
slightly  propped  up  in  bed,  and  the  physician  sitting  as  best  he  may  beside  him  ;  or 
with  the  patient  standing,  as  for  example,  when  a  library  drop-light  is  used,  which  can- 
not be  brought  low  enough  to  illuminate  the  throat  when  the  patient  is  sitting 

The  most  suitable  seat  for  the  patient  is  a  narrow  cane- 
seated  chair,  with  a  straight  back,  sufficiently  high  to  support 
the  head,  and  a  seat  not  more  than  a  foot  in  depth,  which  will 
compel  the  patient  to  sit  erect.  For  the  physician  a  piano 
stool,  which  can  be  raised  or  lowered  to  any  desired  level,  is 
most  convenient ;  but  any  common  chair  can  be  made  to  answer 
the  purpose. 

The  patient  should  be  seated  beside  or  just  in  front  of  the 
table  which  holds  the  instruments.  A  cuspidor  should  be 


MODE   OF    USING   THE    LARYNGOSCOPE.  375 

placed  beside  him,  and  a  glass  of  water  should  be  close  at  hand. 
If  direct  sunlight  is  employed,  the  patient  should  be  placed 
near  the  window,  facing  the  light,  which,  coming  in  over  the 
physician's  shoulders,  falls  directly  upon  the  pharyngeal  mirror. 
With  reflected  sunlight  the  positions  of  patient  and  examiner 
as  regards  the  window  are  reversed.  When  artificial  light  is 
employed,  which  is  usually  the  case,  the  light  should  be  placed 
on  a  level  with  the  patient's  eyes,  and  slightly  behind  him,  so 
that  it  will  not  shine  on  his  face;  and  about  six  inches  distant 
at  one  side,  so  that  the  rays  may  fall  without  obstruction  on 
the  reflector.  If  the  flame  is  placed  much  above  or  below  the 
level  of  the  patient's  eyes,  or  far  from  his  head,  at  one  side,  the 
angle  at  which  the  rays  fall  upon  the  reflector  will  be  so  great 
that  a  good  illumination  will  be  impossible.  The  patient's  head 
should  be  thrown  slightly  backward  (Fig.  56),  so  that  the  edge 
of  the  upper  incisor  teeth  will  be  nearly  on  a  horizontal  plane 
with  the  posterior  margin  of  the  soft  palate. 

The  reflector  may  be  worn  on  the  forehead,  or,  as  I  prefer, 
before  one  eye.  If  the  lamp  is  on  the  patient's  right,  the  re- 
flector should  be  placed  in  front  of  the  examiner's  left  eye,  or 
vice  versa.  The  throat  mirror  may  be  held  in  either  hand,  the 
patient's  tongue  being  held  by  the  other.  For  right-handed 
persons  it  is  easier  at  first  to  hold  the  mirror  with  the  right 
hand,  but  the  left  hand  should  be  educated  to  the  task  as  soon 
as  possible  ;  for  when  other  instruments  are  to  be  used,  the  right 
hand  will  be  required  for  this  purpose.  Even  for  the  purpose 
of  diagnosis  ambidexterity  is  very  desirable,  for  by  holding  the 
mirror  first  with  one  hand  and  then  with  the  other,  any  false 
impressions  of  asymmetry  may  at  once  be  corrected. 

In  making  a  laryngoscopic  examination,  everything  being  in 
readiness,  the  physician  takes  his  position  in  front  of  the  patient, 
and  fixes  the  reflector  in  its  place ;  his  eye  is  now  brought 
within  about  ten  inches  of  the  patient's  lips,  upon  which  the 
light  is  directed.  If  the  lamp  has  been  placed  at  the  proper 
distance,  a  perfect  inverted  image  of  the  flame  will  be  seen  on 
the  patient's  lips,  otherwise  the  light  should  be  moved  back- 
ward or  forward  until  this  result  is  obtained.  The  patient  is 
then  directed  to  protrude  his  tongue,  which  the  physician 
grasps  and  holds  between  his  thumb  and  forefinger,  which  have 
been  previously  enveloped  in  a  soft  napkin.  The  examiner's 


275  THE   THROAT   AND   NASAL   CAVITIES. 

eye  is  then  brought  about  four  inches  nearer,  and  the  light  from 
the  reflector  is  so  directed  that  the  brightest  point  falls  on  the 


FIG.  56. — Position  of  head,  giving  the  best  view  of  larynx,  as  shown  in  small  cut  at 
the  left  (altered  from  Browne). 


FIG.  57. — Position  of  head,  giving  a  poor  view  of  larynx,  as  shown  in  the  small  cut 
at  the  left  (Browne). 

base  of  the  uvula  where  it  must  be  retained.     The  throat  mir- 
ror is  then  warmed  for  a  moment  over  the  lamp,  its  tempera- 


MODE   OF   USING   THE   LARYNGOSOPE. 


277 


ture  tested  on  the  cheek  or  back  of  the  hand,  and  it  is  then 
carried  into  position  in  the  throat. 

Now,  by  a  slight,  steady  movement  of  the  mirror,  the  image 
of  the  larynx  is  brought  into  view  (Fig.  58.) 

The  first  difficulty   which   the   beginner   experiences  is  to 


FIG.  58.— The  laryngoscopic  mirror  in  position,  stem  to  one  side  (Cohen). 

direct  the  light  into  the  mouth,  and  the  second  is  to  keep  it 
there.     These  may  be  readily  overcome  by  practice  and  th 
should  always  be  mastered  on  a  dummy  or  some  other 
before  an  attempt  is  made  to  examine  a  patient. 

Holding  the  tongue.-1\*  patient  should  protrude  the  tongu 
as  far  as  possible  by  the  muscles  of  the  tongue  itseH,  a 
must  be  hdd  gently  by  the  physician  without  an  attempt  to 


378  THE   THROAT    AND   NASAL    CAVITIES. 

draw  it  farther  out,  for  such  an  attempt  would  cause  contrac- 
tion of  its  muscles. 

A  soft  cloth  is  necessary  in  holding  the  tongue,  not  only  for 
neatness,  but,  because  if  it  be  grasped  simply  with  the  fingers  it 
will  slip  away.  In  holding  the  tongue,  the  finger  which  is 
beneath  it  should  be  held  slightly  higher  than  the  edge  of  the 
lower  teeth,  or  the  teeth  may  be  covered  by  a  napkin  to  avoid 
causing  pain,  or  injury  to  the  fraenum. 

Whenever  both  of  the  physician's  hands  are  to  be  occupied 
with  instruments,  the  tongue  may  be  held  by  the  patient. 
Sometimes  I  have  found  this  desirable,  simply  to  overcome  the 
individual's  nervousness. 

Management  of  the  throat  mirror. — The  throat  mirror  em- 
ployed must  correspond  to  the  size  of  the  fauces.  The  one 
which  I  have  found  most  generally  useful  for  adults  is  seven 
eighths  of  an  inch  in  diameter ;  but  mirrors  one  and  one  fourth 
inches  in  diameter,  or  even  somewhat  larger,  may  often  be 
employed.  The  larger  the  mirror  the  better  will  be  the  illu- 
mination. 

Before  being  passed  into  the  throat,  the  mirror  should  be 
warmed  over  the  lamp  for  an  instant,  so  that  the  moisture  of 
the  breath  may  not  condense  upon  it.  Wh^n  a  cool  mirror  is 
first  placed  over  the  flame  a  thin  film  will  be  seen  to  spread 
over  its  surface,  which  disappears  as  soon  as  the  glass  becomes 
warm.  As  soon  as  this  film  disappears  the  mirror  is  of  a 
proper  temperature  for  use. 

Instead  of  warming  the  mirror,  its  surface  may  be  covered 
with  a  solution  of  glycerine  and  water  to  prevent  condensation 
of  moisture  ;  but  this  does  not  leave  so  good  a  reflecting  surface, 
and,  as  a  result,  the  image  will  be  less  distinct.  Other  devices 
have  been  suggested  for  preventing  condensation  of  the  breath 
on  the  mirror,  but  they  are  of  no  practical  value.  The  mir- 
ror is  less  irritating  to  the  fauces  when  warm  ;  and  it  will 
retain  the  heat  as  long  as  it  ought  to  be  kept  in  the  throat. 
The  mirror  should  be  held  like  a  pen-holder  between  the 
thumb  and  fingers,  with  the  hand  bent  slightly  backward  upon 
the  wrist.  It  should  be  passed  horizontally  into  the  mouth 
with  the  reflecting  surface  downward,  and  carried  promptly 
midway  between  the  tongue  and  the  roof  of  the  mouth  back  to 
the  uvula,  which  is  caught  upon  it  and  carried  upward  and 


MODE   OF    USING   THE    LARYNGOSCOPE 

backward,  until  the  rim  of  the  mirror  rests  nearly  against  the 
posterior  wall  of  the  pharynx.  If  the  uvula  hangs  too  low  to 
be  easily  caught  on  the  back  of  the  mirror,  it  may  be  elevated 
by  causing  the  patient  to  take  a  deep  inspiration  or  to  phonate 
the  syllables  "ah  "  or  "  eh."  If  the  throat  will  tolerate  it,  the 
mirror  may  be  rested  against  the  posterior  wall  of  the  pharynx. 

The  stem  of  the  mirror  may  be  held  either  above  or  at  one 
side,  and  its  handle  should  be  carried  outward  toward  the 
angle  of  the  mouth,  so  that  the  hand  will  not  obstruct  the 
light.  The  angle  of  the  mirror  should  be  about  forty-five 
degrees  to  the  plane  of  the  Horizon,  though,  in  practice,  it  will 
be  found  that  good  views  can  be  obtained  from  different  points 
with  the  mirror  in  various  positions,  by  altering  the  relative 
positions  of  the  physician  and  patient,  or  by  inclining  the 
patient's  head  more  or  less. 

If  the  light  has  been  properly  directed,  it  will  now  fall  on  the 
mirror,  whence  it  will  be  more  or  less  perfectly  reflected  into 
the  larynx,  an  inverted  image  of  which  will  be  seen  in  the  mir- 
ror (Fig.  58,  page  277).  If  the  larynx  is  not  perfectly  brought 
into  view,  the  mirror  may  be  slightly  rotated  or  its  obliquity 
altered  by  moving  the  handle ;  but  these  movements  must  be 
few  and  they  must  be  made  with  decision,  for  if  they  are  made 
with  an  uncertain,  tremulous  hand,  or  if  many  movements  are 
made,  retching  is  likely  to  be  produced,  which  will  usually 
prevent  further  examination  of  the  larynx.  At  this  point  in 
the  manipulation,  beginners  generally  have  considerable  diffi- 
culty either  by  losing  the  light  or  by  being  unable  to  obtain  a 
view  of  the  larynx,  on  account  of  an  improper  position  of  the 
throat  mirror.  In  either  case,  the  mirror  should  be  promptly 
withdrawn  and  re-introduced  ;  for  if  it  is  held  in  position  while 
the  light  is  being  re-arranged,  or  if  it  is  moved  about  in  the 
throat  to  secure  another  view,  it  is  likely  to  irritate  the  fauces. 

With  the  throat  mirror  in  position,  you  will  obtain  a  more 
or  less  perfect  view  of  the  base  of  the  tongue  and  of  the  larynx. 
If  only  the  base  of  the  tongue  or  the  upper  part  of  the  epi- 
glottis is  brought  into  view,  by  depressing  the  handle  slightly 
you  will  expose  the  parts  below ;  or  if  these  are  first  brought 
into  view,  the  superior  structures  may  be  exposed  by  elevating 
the  handle.  By  rotating  the  mirror  slowly,  the  lateral  walls  of 
the  pharynx  or  larynx  may  be  exposed. 


2go  THE   THROAT   AND   NASAL   CAVITIES. 

The  hand  which  holds  the  mirror  may  be  steadied  by  rest- 
ing the  ring  and  little  fingers  on  the  patient's  cheek. 

The  mirror  should  not  be  kept  in  the  throat  more  than 
twenty  or  thirty  seconds,  but  the  examination  may  be  con- 
tinued by  re-introducing  it  several  times. 

Whenever  the  slightest  indication  of  retching  occurs,  the 
mirror  must  be  instantly  withdrawn,  but,  after  a  few  moments, 
another  trial  may  be  made,  when  the  patient  will  usually 
tolerate  it  as  well  as  in  the  first  instance. 

When  inserting  the  mirror,  be  careful  that  its  reflecting  sur- 
face does  not  touch  the  tongue,  aftd  that  its  back  does  not  rub 
against  the  palate.  The  former  accident  clouds  the  reflecting 
surface,  and  either  is  likely  to  cause  retching  or  an  attempt  to 
swallow,  which  will  prevent  the  examination. 


LECTURE  XXV. 
LARYNGOSCOPY  Continued— RHINOSCOPY. 

OBSTACLES   TO   LARYNGOSCOPY. 

Obstacles  are  frequently  met  with  in  making  laryngoscopic 
examination,  though  by  a  little  tact  and  patience  they  can 
usually  be  overcome,  at  least  at  a  second  sitting.  You  should 
never  expect  a  thorough  view  of  the  larynx  without  intro- 
ducing the  mirror  two  or  three  times  ;  however,  if  the  patient's 
throat  is  not  sensitive,  by  rotating  the  mirror  slightly  you  may 
be  able  sometimes  to  inspect  the  entire  larynx  with  a  single 
introduction  of  the  mirror. 

The  principal  obstacles  to  be  overcome  are  :  an  elongated 
uvula,  enlarged  tonsils,  irritable  fauces,  a  short  frasnum,  arch- 
ing upward  of  the  back  of  the  tongue,  and  a  pendent  epiglottis 
In  two  cases,  one  an  actor,  and  the  other  an  elocutionist,  I 
have  found  difficulty  in  inspecting  the  larynx  that  was  appar- 
ently caused  by  hypertrophy  of  the  lingual  muscles;  which 
greatly  restricted  the  space  between  the  tongue  and  posterior 
wall  of  the  pharynx. 

ELONGATED  UVULA. — An  elongated  uvula,  hanging  below 
the  mirror,  appears  as  though  curled  over  the  lower  edge  and 
resting  upon  the  reflecting  surface.  This  is  very  confusing 
and  prevents  a  view  of  the  parts  below. 


o 

FIG.  59. — Scissors  for  amputating  the  uvula. 

To  obviate  this  difficulty  in  ordinary  cases,  it  is  only  neces- 
sary to  use  a  large  mirror  and  to  be  careful  in  placing  it 
against  the  uvula.  Mirrors  have  been  devised  with  a  little 


2g2  THE   THROAT   AND   NASAL   CAVITIES. 

pocket  in  the  back  for  catching  the  uvula,  but  I  am  not  aware 
that  they  are  now  in  use.  If  the  uvula  is  so  long  that  it  cannot 
be  managed  with  a  large  mirror,  it  may  be  contracted  by  astrin- 
gents; or  if  these  are  inadequate,  it  should  be  amputated  and 
the  examination  made  at  a  subsequent  sitting. 

IRRITABLE  FAUCES. — A  patient  will  sometimes  retch  or  gag 
if  a  person  simply  looks  into  his  mouth,  and  others  will  do  so 
when  the  tongue  is  protruded.  In  still  other  instances,  this 
occurs  as  soon  as  the  throat  mirror  touches  the  fauces.  To 
overcome  these  difficulties,  the  patient  should  be  fully  im- 
pressed with  the  necessity  of  the  examination,  and  he  should 
be  urged  to  exert  himself  to  prevent  retching ;  the  mirror 
should  then  be  introduced  during  a  deep  inspiration  or  as  the 
patient  says  "eh"  or  "ah,"  which  elevates  the  uvula  and,  by 
thus  avoiding  the  necessity  for  pressure  against  the  palate, 
often  induces  much  greater  tolerance  of  the  instrument. 

In  nervous  patients  it  is  often  best,  for  the  sake  of  gaining 
their  confidence,  to  introduce  the  mirror  once  or  twice  so  as 
just  to  touch  the  palate,  and  then  withdraw  it  at  once  without 
attempting  to  see  the  larynx. 

If  these  devices  fail,  the  most  feasible  method  for  overcoming 
this  difficulty  is  to  allow  the  patient  to  suck  ice  for  fifteen  or 
twenty  minutes,  which  will  produce  some  degree  of  temporary 
local  anaesthesia. 

Many  persons,  in  whom  the  pharynx  is  sensitive,  will  tolerate 
an  examination  at  a  second  or  third  sitting,  in  whom  hardly  a 
glimpse  can  be  obtained  at  the  first.  In  such  cases  it  is  a 
good  plan  to  have  the  patient  educate  the  throat  to  bear  instru- 
ments, by  introducing  a  spoon-handle  against  the  uvula  before 
a  mirror  several  times  daily  during  the  interim.  In  cases  of 
irritability  of  the  fauces,  some  laryngologists  recommend  titilla- 
tion  of  the  palate  with  a  probe  or  a  pen-holder  before  attempt- 
ing to  introduce  the  mirror,  in  order  that  the  parts  may  become 
accustomed  to  manipulation.  Various  other  devices  have  been 
recommended  for  overcoming  the  sensitiveness  of  the  throat, 
such  as  painting  the  fauces  with  chloroform  and  morphia,  in- 
halation of  a  few  whiffs  of  chloroform,  and  the  internal  use  of 
large  doses  of  bromide  of  potassium  ;  but  none  of  these  meas- 
ures are  very  satisfactory.  Ordinarily  we  will  succeed  best 
simply  by  patience  and  care  in  introducing  and  holding  the 


MODE   OF    USING   THE   LARYNGOSCOPE. 

mirror,  supplemented,  when  necessary,  by  the  use  of  ice.  The 
fauces  are  more  irritable  when  the  stomach  is  disordered,  and 
during  digestion  than  at  other  times,  therefore  it  is  best,  when- 
ever the  throat  is  sensitive,  not  to  make  examinations  until 
three  or  four  hours  after  meals. 

SHORT  FR^NUM.— A  short  fraenum  is  one  of  the  minor  obsta- 
cles. If  it  proves  very  troublesome  it  may  be  easily  relieved 
with  a  pair  of  blunt-pointed  scissors. 

ARCHING  OF  THE  TONGUE.— In  some  patients,  just  as  the 
mirror  is  being  carried  between  the  teeth,  the  posterior  part  of 
the  tongue  will  arch  upward,  so  as  to  touch  the  soft  palate,  and 
thus  prevent  the  passage  of  the  mirror  into  the  fauces ;  or  it 
will  intercept  the  rays  of  light  after  the  mirror  is  in  position  so 
that  a  view  cannot  be  obtained. 

This  difficulty  is  best  overcome  by  cautioning  the  patient 
not  to  strain,  and  by  care  not  to  draw  the  tongue  far  out  of 
the  mouth,  or  downward  toward  the  chin. 

Sometimes.a  good  view  of  the  larynx  can  be  obtained  in  these 
instances  by  holding  the  throat  mirror  nearly  horizontal  against 
the  palate,  and  reflecting  the  light  upon  it  from  below  upward. 
In  some  cases,  by  giving  the  patient  a  hand  mirror,  so  that  he 
can  watch  the  movements  of  the  tongue,  he  will  be  able  to 
keep  its  base  depressed.  Other  patients  will  have  to  practice 
before  a  mirror  at  home  for  several  days,  before  control  of  the 
tongue  can  be  obtained.  Tongue  depressors  seem  indicated  in 
these  cases,  but  they  are  of  little  value. 

ENLARGED  TONSILS. — When  the  tonsils  are  greatly  enlarged, 
they  may  prevent  the  introduction  of  any  mirror  into  the  throat, 
and  in  such  cases  the  only  remedy  is  excision.  When  these 
glands  are  only  moderately  enlarged  it  will  sometimes  be  im- 
possible to  introduce  the  ordinary  mirror  without  touching 
them  both,  and  perhaps  causing  retching ;  but  in  many  cases, 
if  the  mirror  is  carried  promptly  between  and  behind  the  ton- 
sils, the  throat  will  remain  quiet,  even  though  both  sides  have 
been  touched.  In  other  cases  it  is  best  to  use  an  oval  mirror, 
which  may  be  passed  into  the  fauces  without  touching  the 

tonsils. 

PENDENT  EPIGLOTTIS.— A  large  or  pendent  epiglottis  is  some 
times  an  insurmountable  obstacle  to  laryngoscopy.  When  the 
glosso-epiglottidean  ligaments  are  relaxed,  or  when  the  epiglot- 


284  THE   THROAT   AND   NASAL  CAVITIES. 

tis  is  swollen,  it  falls  downward,  so  that  its  free  edge  may  rest 
against  the  pharyngeal  wall,  and  thus  leave  little  if  any  space 
for  the  passage  of  light.  In  some  of  these  cases  we  can  obtain 
a  view  of  the  larynx  by  causing  the  patient  to  utter  a  high 
falsetto  note,  or  to  laugh  or  cough.  By  this  means  the  epiglot- 
tis is  thrown  upward  with  a  sudden  jerk.  A  vocal  sound,  as 
"ah"  or  "eh,"  made  during  inspiration,  will  have  a  similar 
effect.  In  other  instances  it  is  only  necessary  for  the  patient 
to  draw  a  deep  breath  in  order  to  raise  the  epiglottis  suffi- 
ciently to  give  a  view  beneath  it.  Frequently  by  passing  the 
mirror  lower  into  the  pharynx,  and  more  perpendicularly  than 
usual,  the  inferior  surface  of  the  epiglottis  and  other  portions 
of  the  larynx  may  be  seen. 

Various  instruments  have  been  devised  for  lifting  the  epi- 
glottis. The  best  of  these  is  a  stout  whalebone  or  metallic  rod, 
bent  nearly  to  a  right  angle  about  an  inch  from  the  end,  with 
its  terminal  extremity  turned  slightly  backward.  This  instru- 
ment is  known  as  Voltolini's  staff.  It  may  be  passed  behind 
the  lip  of  the  epiglottis,  so  as  to  lift  and  draw  it  forward. 

When  operations  are  to  be  performed,  and  occasionally  for 
simple  inspection,  some  special  instrument  may  be  necessary  to 
catch  the  lip  of  the  epiglottis  and  draw  it  forward.  For  this 
purpose  Bruns'  pincette  is  the  most  serviceable.  However, 


FIG.  60. — Brans'  pincette. 

instruments  of  this  kind  usually  cause  so  much  irritation  that 
they  cannot  be  tolerated. 

It  occasionally  happens  that  only  the  posterior  part  of  the 
larynx  can  be  seen,  and  the  vocal  cords  cannot  be  brought  into 
view.  In  such  instances  the  movements  of  the  arytenoid  carti- 
lages may  be  seen  sufficiently  to  enable  us  to  judge  of  the 
mobility  of  the  cords ;  but  the  appearance  of  the  tissue  covering 
them  cannot  be  taken  as  an  accurate  indication  of  the  condition 
of  the  mucous  membrane  in  other  portions  of  the  larynx. 

After  familiarizing  yourselves  with  the  laryngoscope  and  the 
rules  for  its  use,  before  attempting  laryngoscopy  on  a  living 


INFRA-GLOTTIC   LARYNGOSCOPY. 


285 


subject,  you  should  practice  for  some  time  on  a  dummy,  or  on 
a  larynx  which  has  been  removed  from  the  body  and  attached 
to  a  standard.  If  these  cannot  be  obtained,  you  may  easily 
make  a  model  by  boring  a  couple  of  holes  in  a  block  of  wood 
— one  hole  about  two  inches  in  diameter  to  represent  the 
mouth,  and  the  other  about  an  inch  in  diameter,  intersecting 
the  first  at  an  angle  of  eighty  degrees,  to  represent  the  larynx. 
By  practicing  on  any  of  these,  you  may  familiarize  yourselves 
with  the  management  of  the  light,  the  reflector,  and  throat 
mirror,  and  you  may  educate  your  hands  to  steadiness. 

Having  learned  to  control  your  hands  so  that  the  mirror 
will  not  tremble,  and  to  reflect  the  rays  of  light  accurately  to 
the  point  you  wish  to  observe,  you  may  begin  to  practice 
upon  the  living  subject.  At  first,  when  possible,  you  should 
practice  upon  a  patient  who  has  been  trained,  so  that  your  lack 
of  skill  will  not  induce  retching ;  subsequently  you  must  prac- 
tice upon  healthy  individuals  for  some  time,  in  order  to  become 
perfectly  familiar  with  the  appearance  of  the  healthy  larynx, 
so  that  any  deviations  from  a  physiological  condition  will  be 
at  once  recognized. 


FIG  61  .—Infra-glottic  laryngoscopy.     Small  metallic  mirror  in  position  in  the  fenes- 

tra  of  the  tracheal  canula. 

INFRA-GLOTTIC  LARYNGOSCOPY. 

It  is  sometimes  desirable  to  inspect  the  larynx  from  below, 
which  may  be  done,  after  tracheotomy,  through  a  fenestra 
in  the  canula,  by  the  aid  of  a  small  metallic  mirror  ( 


286 


THE   THROAT   AND    NASAL   CAVITIES. 


RHINOSCOPY. 

Rhinoscopy,  or  inspection  of  the  vault  of  the  pharynx  and 
posterior  nares,  is  practiced  with  similar  instruments  to  those 
used  in  the  inspection  of  the  larynx,  and  in  much  the  same 
manner,  excepting  that  a  smaller  mirror  is  employed  and  its 
reflecting  surface  is  turned  upward  instead  of  downward. 

In  rhinoscopy,  the  patient  should  sit  erect,  and  the  head  must 
not  be  thrown  backward,  but  may  be  slightly  inclined  forward. 


FIG.  62. — Position  for  rhinoscopy,  showing  also  curve  in  stem  of  mirror.     (Slightly 
altered  from  Browne.) 

The  physician  should  take  a  position  in  front,  the  same  as  for 
laryngoscopy,  or  on  a  slightly  higher  level,  and  the  light  should 
be  placed  as  for  inspection  of  the  larynx,  excepting  that  it 
should  be  on  a  level  with  the  patient's  mouth  instead  of  his 
eyes.  The  patient's  tongue  should  not  be  protruded,  but  must 
be  left  in  the  floor  of  the  mouth  where  it  will  generally  need 
to  be  held  by  a  tongue  depressor,  though  some  patients  can 
control  it  better  without  an  instrument.  The  throat  mirror  in 
general  use  is  a  number  one  or  number  two  laryngeal  mirror, 
the  stem  of  which  is  bent  to  conform  it  to  the  floor  of  the 
mouth  (Fig.  62).  It  is  to  be  warmed  and  introduced  with  the 


RHINOSCOPY.  2g^ 

same  care  as  in  laryngoscopy,  with  the  reflecting  surface  up- 
ward. It  should  be  carried  back  to  the  posterior  pharyngeal 
wall,  though  it  is  better  to  avoid  touching  the  latter.  The  sur- 
face of  the  mirror  will  then  be  at  an  angle  of  about  thirty 
degrees  to  a  horizontal  plane.  The  stem  may  be  rested  on  the 
dorsum  of  the  tongue,  but  care  must  be  taken  not  to  touch 
the  base  of  this  organ.  The  handle  should  be  depressed  nearly 
to  the  lower  incisor  teeth  (Fig.  62).  A  common  caue  of  failure 
in  this  examination  is  holding  the  mirror  handle  too  high. 

The  mirror  should  be  introduced  first  on  one  side  of  the 
uvula  and  then  on  the  other,  to  give  a  view  of  different  parts. 
In  some  cases  a  larger  mirror  may  be  used  if  it  is  held  com- 
pletely below  the  uvula. 

When  the  mirror  is  in  position,  if  only  the  posterior  wall  of 
the  pharynx  is  seen,  in  order  to  expose  the  posterior  nares,  the 
handle  must  be  still  farther  depressed,  or  the  mirror  must  be 
withdrawn  and  bent  more  nearly  to  a  right  angle  with  the  stem. 
If  at  first  only  the  uvula  and  posterior  surface  of  the  palate 
are  exposed,  the  handle  must  be  elevated  to  obtain  a  view  of 
the  posterior  nares  or  vault  of  the  pharynx.  The  mirror  may 
be  rotated  slightly  to  obtain  an  image  of  the  lateral  walls  of  the 
pharynx,  or  of  the  orifices  of  the  Eustachian  tubes. 

OBSTACLES   TO   RHINOSCOPY. 

The  principal  difficulties  which  are  met  with  in  the  exami- 
nation of  the  posterior  nares  are,  irritability  of  the  tongue, 
which  causes  the  patient  to  retch  whenever  an  attempt  is  made 
to  depress  it  with  the  spatula ;  an  elongated  or  sensitive  uvula ; 
irritablity  of  the  fauces ;  or  too  close  approximation  of  the 
uvula  and  palate  to  the  posterior  pharyngeal  wall. 

IRRITABILITY  OF  THE  TONGUE. — This  condition  will  some- 
times prevent  the  use  of  a  tongue  depressor,  but  this  instru- 
ment may  generally  be  employed  if  the  physician  is  careful  not 
to  allow  it  to  slip  too  far  back  on  the  base  of  the  organ.  In 
many  cases  it  is  not  necessary  to  depress  the  tongue  with  any 
instrument,  if  patients  are  instructed  to  allow  it  to  remain  pas- 
sive in  the  floor  of  the  mouth.  A  hand  mirror,  in  which  the 
patient  can  see  his  tongue,  will  sometimes  aid  him  materially 
in  controlling  it.  In  other  cases  the  tongue  may  be  held  as  in 
laryngoscopy. 


2gg  THE    THROAT   AND   NASAL   CAVITIES. 

Some  one  of  these  methods  will  nearly  always  overcome  this 
difficulty;  but  if  they  should  ail  fail,  the  patient  must  practice 
at  hotne  before  a  mirror  until  a  spatula  can  be  tolerated,  or 
until  the  tongue  can  be  held  without  one. 

Instruments  have  been  constructed  which  combine  a  tongue 
depressor  and  the  throat  mirror ;  but  they  are  not  necessary, 
for,  whenever  the  physician  desires  to  use  both  hands,  the  care 
of  the  spatula  may  be  intrusted  to  the  patient.  Instruments 
of  this  kind  are  objectionable,  as  the  depressor  necessarily 
greatly  restricts  the  movements  of  the  mirror. 

ELONGATED  UVULA. — When  the  palate  and  uvula  are  so  re- 
laxed as  to  become  an  obstacle  to  the  use  of  the  rhinoscopic 
mirror,  they  may  be  contracted  by  astringents.  If  the  uvula 
is  too  long  to  be  managed  in  this  manner,  it  should  be  excised. 

Various  instruments  have  been  devised  for  raising  the  uvula 
and  drawing  it  forward,  but  they  are  of  very  little  service  as 
they  usually  cause  so  much  irritation  that  they  cannot  be 
borne. 

IRRITABILITY  OF  THE  FAUCES. — This  condition  can  be  over- 
come in  many  instances  by  allowing  the  patient  to  suck  bits  of 
ice  for  ten  or  fifteen  minutes.  In  other  cases  prolonged  prac- 
tice in  holding  the  tongue  and  in  touching  the  palate  and 
pharyngeal  wall  with  a  spoon  handle  must  be  resorted  to  by 
the  patient  at  home. 

CLOSURE  OF  THE  POST-PALATINE  SPACE,  by  contraction  of 
the  palatine  muscles,  often  occurs  the  moment  a  patient  opens 
his  mouth,  and  it  sometimes  continues  in  spite  of  our  best 
directed  efforts  to  overcome  it.  This  is  the  most  common 
difficulty  with  which  we  have  to  contend  in  illuminating  the 
vault  of  the  pharynx  and  the  posterior  nares. 

Sometimes  this  difficulty  may  be  overcome  by  cautioning  the 
patient  to  allow  the  fauces  to  remain  passive  when  the  mouth  is 
opened,  or,  by  directing  him  to  simply  open  the  mouth  wide 
without  attempting  to  show  the  throat.  Then,  by  introducing 
the  mirror  carefully  so  as  not  to  touch  any  part  of  the  fauces, 
and  withdrawing  it  and  re-introducing  it  several  times  if  neces- 
sary without  attempting  to  obtain  a  view  behind  the  palate, 
the  patient's  confidence  may  be  secured  and  the  examination 
completed. 

If  the  patient  can  be  taught  to  breathe  quietly  through  the 


RHINOSCOPY.  2gQ 

nose  during  the  examination  the  palate  will  hang  loosely  so  as 
to  cause  no  trouble. 

Sometimes  a  view  may  be  secured  by  directing  the  patient 
to  sound  the  letters  "n"  or  "ng."  Frequently  a  glimpse  may 
be  had  if  the  patient  will  attempt  to  expire  through  the  nose. 

Various  palate  or  uvula  hooks  have  been  constructed  for  the 
purpose  of  overcoming  the  difficulty  ;  but,  as  has  been  well 
stated,  the  time  spent  in  teaching  the  patient  to  tolerate  them 
is  usually  more  than  is  necessary  to  educate  the  throat  to  main- 
tain a  position  which  will  require  no  instrument.  Time, 
patience,  and  frequent  practice  by  the  patient  at  home,  must  be 
the  main  dependence  for  successful  examination  in  these  cases. 

When  operations  are  to  be  performed,  the  palate  may  be 
drawn  forward  by  a  thread  passed  through  the  uvula,  or  by 
tapes  passed  through  the  nares  by  means  of  a  Bellocq's  canula 
and  brought  out  of  the  mouth  and  tied.  Or  it  may  be  done  by 
means  of  a  broad,  strong  uvula  hook  or  palate  elevator.  The 
palate  elevator  ordinarily  sold  (Fig.  63)  is  only  two  eighths  or 
three  eighths  of  an  inch  in  width,  and  is  therefore  too  small 
for  this  purpose.  Combinations  of  mirrors  and  uvula  holders 


FIG.  63. — Palate  elevator. 

have  been  constructed,  but  they  do  not  give  general  satisfac- 


tion. 


FIG.  64. — Rhinoscope  with  uvula  holder. 


LECTURE    XXVI. 
THE  NORMAL  LARYNX  AND  POST-NASAL  SPACE. 

LARYNX. 

The  image  of  the  larynx,  as  seen  in  the  throat  mirror,  is 
inverted,  so  that  the  anterior  portion,  which  is  nearest  the 
observer,  appears  in  the  glass  above  and  farthest  from  its  sur- 
face, and  the  posterior  portion  appears  below  and  close  to  the 
mirror.  The  sides  of  the  larynx  are  not  reversed  in  the  image  ; 
what  appears  to  the  physician's  right,  and  the  patient's  left,  is, 
in  reality,  the  left  side  of  the  larynx  ;  and  the  right  side  appears 
in  its  normal  relation. 


FIG.  65. — Relative  relations  of  larynx  and  its   image  in  the  laryngoscopic  mirror 
(Cohen). 

An  image  of  the  whole  larynx  can  seldom  be  obtained  at  a 
single'glance ;  J)ut  by  slight  rotation  of  the  mirror,  with  eleva- 


THE   NORMAL   LARYNX.  2    j 

tion  and  depression  of  the  handle,  so  as  to  alter  the  plane  of  the 
reflecting  surface,  the  different  parts  may  be  brought  into  view. 
The  vocal  cords,  because  of  their  bright  appearance  and  fre- 
quent respiratory  movements,  usually  attract  the  most  atten- 
tion, and  when  once  seen  can  never  be  forgotten  ;  but  the 
epiglottis  comes  first  into  view. 


TONGUE 


FIG.  66. — Normal  larynx  in  respiration,  enlarged.  Parts  exaggerated  to  render  them 
more  conspicuous,  i,  lingual  surface  of  epiglottis  ;  2,  laryngeal  surface  of  epiglottis  ; 
3,  indented  crest  of  epiglottis  ;  4,  pharyngo-epiglottic  fold  ;  5,  ary-epiglottic  fold  ;  6, 
cushion  of  epiglottis  ;  7,  glosso-epiglottic  ligament ;  8,  valeculae  ;  9,  pyriform  sinus  . 
10,  posterior  pharyngeal  wall  and  entrance  into  oesophagus  ;  n,  inter-arytenoid  incisure; 
12,  cartilage  of  Santorini  ;  13,  inter-arytenoid  fold;  14,  cartilage  of  Wrisberg  ;  15, 
ventricular  band  ;  16,  vocal  cord  ;  17,  ventricle  ;  18,  posterior  vocal  process ;  19,  thy. 
roid  cartilage  ;  20,  cricorthyroid  membrane  ;  21,  cricoid  cartilage  ;  22,  rings  of  trachea; 
23,  insterspaces  between  rings  of  trachea  (Cohen). 

EPIGLOTTIS. — The  epiglottis  is  a  leaf-like  valve,  which  covers 
the  superior  opening  of  the  larynx  and  closes  it  during  deglu- 
tition. This  varies  greatly  in  size  and  form  in  different  indi- 
viduals (Figs.  67  to  72).  It  may  be  long  and  thin,  or  short 
and  thick;  it  may  be  broad,  or  narrow  and  pointed;  its  free 
edge  may  be  curved  like  a  bow,  it  may  be  folded  in  upon  itself 
like  a  scroll  in  what  is  known  as  the  Jewsharp  form  (Fig.  71), 
or  it  may  be  asymmetric.  It  may  cover  the  whole  larynx,  or  it 
may  be  nearly  invisible.  Sometimes  only  the  upper  or  anterior 
surface  of  the  epiglottis  can  be  seen,  at  other  times  its  lower 
portion  or  laryngeal  surface  is  most  visible  ;  again,  only  its  tip 
is  brought  into  view,  and  still  again  considerable  portions  of 
both  the  anterior  and  the  posterior  surfaces  may  be  seen  at  tne 
same  time. 


THE   THROAT   AND   NASAL   CAVITIES. 

With  respiration,  the  lip  of  the  epiglottis  rises  and  falls 
slightly.  With  phonation  it  is  generally  thrown  upward,  and 
in  deglutition  it  is  carried  downward  to  the  posterior  border 
of  the  larynx. 

The  base  of  the  epiglottis — but  in  reality  the  apex  of  the 
cartilage — is  connected  with  the  thyroid  cartilage  at  its  reced- 
ing angle  by  a  long  narrow  band,  known  as  the  thyro-epiglottic 
ligament;  a  small  band,  the  hjo-epiglottic  ligament,  connects 
it  with  the  posterior  surface  of  the  hyoid  bone.  The  lingual 
or  upper  surface  of  this  cartilage  usually  curves  forward,  its 
concavity  being  directed  toward  the  base  of  the  tongue.  Its 
covering  of  mucous  membrane  forms  a  median  and  two  lateral 
folds,  which  are  known  as  the  glosso-epiglottic  folds.  The 
central  one  of  these  is  also  called  the  frgenum  of  the  epiglottis, 
or  the  glosso-epiglottic  ligament  as  it  contains  a  ligamentous 
band.  The  lateral  folds  contain  no  ligamentous  tissue  and  are 
frequently  absent.  The  laryngeal  or  inferior  surface  curves  in 
a  reverse  direction.  It  is  convex  from  above  downward,  and 
concave  from  side  to  side.  To  its  sides  are  attached  the 
pharyngo-epiglottic  and  the  ary-epiglottic  folds. 

The  whole  epiglottis  is  seldom  visible  even  to  a  skilful  laryn- 
gologist.  Usually  a  portion  of  its  upper  surface  is  visible  on 
each  side.  In  the  middle,  its  laryngeal  surface  is  turned 
upward  like  a  lip,  and  below  this  a  small  prominence  may  fre- 
quently be  seen  near  the  base  of  the  epiglottis,  which  is  known 
as  its  cushion,  pad,  or  protuberance  (Fig.  69). 

In  order  to  obtain  a  good  view  of  the  laryngeal  surface  of  the 
epiglottis,  the  patient  should  be  directed  to  sound  a  high  note 
quickly  and  with  considerable  force.  This  throws  the  cartilage 
upward  with  a  sudden  jerk.  An  inspiration  accompanied  with 
sound  or  an  ironical  laugh  will  answer  the  same  purpose. 

The  color  of  this  organ  varies  in  different  parts.  The  upper 
surface  is  of  a  pinkish  hue,  and  frequently  blood-vessels  may  be 
seen  crossing  it.  The  lip  looks  like  a  yellow  cartilage,  as  it 
really  is,  covered  with  mucous  membrane.  The  cushion  gen- 
erally appears  of  a  much  brighter  red  color  than  other  portions 
of  the  epiglottis.  When  the  whole  of  the  laryngeal  surface 
can  be  seen,  it  often  has  a  uniform  bright-red  color,  which 
might  be  easily  mistaken  for  congestion.  When  only  the  edge 


THE   NORMAL   LARYNX. 


293 


of  the  epiglottis  is  visible,  it  appears  like  a  pale  whitish  line 
just  beneath  the  base  of  the  tongue. 

THE  VALECUL*:.— Upon  either  side  of  the  frsenum,  between 


FIG  67. 


FIG.  68. 


FIG.  69. 


FIG.  70. 


FIG.  71. 


FIG.  72. 


FIGS.  67  to  72. — Normal  larynx,  showing  various  forms  of  epiglottis  and  supra-aryte- 
noid  cartilages. 

FIG   67 — Pitcher-shaped  inter-arytenoid  fold.     Phonation. 

FIG.  68. — Lapping  of  arytenoid  cartilages  in  phonation,  with  gaping  of  vocal  cords. 

FIG.  69. — Cushion  of  epiglottis  visible  ;  no  gaping  of  vocal  cords  in  phonation. 

FIG    70  — Pointed  epiglottis.     Ventricles  distinct.     Inspiration. 

FIG.  71. — "  Jewsharp  "  or  omega-like  epiglottis. 

FIG.  72. — Female  larynx  in  respiration  (Cohen). 

The  female  larynx  may  have  the  form  shown  in  any  of  the  preceding  figures. 

the  epiglottis  and  the  base  of  the  tongue,  are  seen  two  sinuses 
closely  resembling  depressions,  which  might  be  caused  by 
pressing  the  tips  of  two  fingers  into  some  soft  substance  ;  these 


2Q4  THE   THROAT   AND   NASAL   CAVITIES. 

are  known  as  the  lingual  sinuses,  or  the  valeculae  (Fig.  66,  page 
291).  They  vary  greatly  in  depth  and  in  width  in  different 
individuals,  and  in  various  positions  of  the  epiglottis  in  the  same 
individual.  These  sinuses  should  always  be  examined,  as  they 
frequently  give  lodgment  to  portions  of  food  which  are  a 
source  of  irritation,  and  they  are  sometimes  the  seat  of  ulcers. 

ARYTENOID  CARTILAGES.  —  The  arytenoid  cartilages  —  so 
named  on  account  of  their  apparent  resemblance  during  phona- 
tion  to  the  nose  of  a  pitcher — appear  beneath  the  free  edge  of 
the  epiglottis.  They  are  two  in  number,  one  upon  each  side. 
They  are  located  at  the  back  of  the  larynx,  resting  upon  the 
upper  border  of  the  cricoid  cartilage.  Each  of  these  cartilages 
is  somewhat  pyramidal.  The  apex,  which  is  slightly  pointed 
and  curved  upward  and  inward,  is  surmounted  by  a  small 
conical  nodule,  which  has  been  named  the  caruncula  laryngis, 
or  cartilage  of  Santorini. 

To  expose  the  anterior  or  laryngeal  surface  of  the  ary tenoids, 
the  head  should  be  thrown  slightly  backward  during  a  deep 
inspiration,  and  the  light  should  be  directed  more  posteriorly 
than  in  illuminating  the  cords,  by  holding  the  throat  mirror  more 
nearly  horizontal.  To  expose  their  posterior  or  pharyngeai 
surface,  the  head  should  be  nearly  erect,  and  the  mirror  should 
be  held  as  just  directed  while  the  voice  is  sounded. 

CARTILAGES  OF  SANTORINI. — The  cartilages  of  Santorini  are 
most  prominent  when  the  glottis  is  closed,  as  in  phonation. 
The  mucous  membrane  immediately  covering  their  apices  is  of 
a  lighter  hue  than  that  in  other  parts  of  the  larynx,  but  the 
light  color  is  usually  surrounded  by  a  zone  of  deeper  red. 

CARTILAGES  OF  WRISBERG. — Just  external  to  the  cartilage  of 
Santorini,  in  the  fold  of  mucous  membrane  which  extends  on 
either  side  to  the  edge  of  the  epiglottis,  is  a  prominence  known 
as  the  cuneiform  cartilage,  or  cartilage  of  VVrisberg. 

These  cartilages  vary  considerably  in  form  in  different  indi- 
viduals. They  are  usually  round,  but  they  are  occasionally 
triangular,  the  apices  being  directed  downward.  Sometimes 
they  are  hardly  visible,  but  they  are  generally  quite  distinct 
and  fully  as  large  as  the  cartilages  of  Santorini.  These,  like 
the  corniculse,  are  of  a  lighter  color  than  the  folds  which  con- 
tain them,  but  they  are  usually  surrounded  by  a  zone  of  mucous 
membrane  redder  than  that  of  the  general  surface. 


THE   NORMAL   LARYNX.  2    . 

In  a  few  instances  a  small  nodule,  due  to  a  third  cartilage,  is 
seen  between  the  cartilages  of  Wrisberg  and  the  cartilages  of 
Santorini  on  either  side.  The  cartilages  of  Wrisberg  and  those 
of  Santorini  are  sometimes  termed  the  supra-arytenoid  carti- 
lages. 

ARYTENO-EPIGLOTTIDEAN  FOLDS.— The  aryteno-epiglottid- 
ean  or  the  ary-epiglottic  folds  constitute  the  lateral  and  part 
of  the  posterior  border  of  the  superior  opening  of  the  larynx. 
They  consist  of  folds  of  mucous  membrane,  one  on  either  side, 
which  extend  like  bows  from  the  arytenoid  cartilages  up- 
ward and  forward  to  the  sides  of  the  epiglottis.  They  are 
usually  quite  thick,  but  are  occasionally  thin  and  sharp.  In 
color  they  closely  resemble  the  gums,  and  are  somewhat  lighter 
than  the  zones  about  the  bases  of  the  supra-arytenoid  carti- 
lages. 

PYRAMIDAL  SINUSES. — External  to  these  folds,  and  between 
them  and  the  wings  of  the  thyroid  cartilage,  are  found  the 
pyramidal,  pyriform,  or  laryngo-pharyngeal  sinuses.  The 
broad  end  of  each  sinus  is  directed  forward,  and  its  apex  back- 
ward. It  is  bounded  internally  by  the  quadrangular  membrane, 
the  upper  border  of  which  is  formed  by  the  ary-epiglottic  fold  ; 
anteriorly  by  the  wing  of  the  thyroid  cartilage ;  and  laterally 
by  the  wall  of  the  pharynx.  Like  the  valeculae,  these  sinuses 
often  give  lodgment  to  foreign  bodies,  and  they  are  fre- 
quently the  seat  of  ulcerations. 

VENTRICULAR  BANDS,  known  also  as  the  superior  or  false 
vocal  cords,  the  regulators  of  the  glottis,  or  the  superior  liga- 
ments of  the  larynx.  These  are  thick  folds  of  mucous  membrane 
which  stretch  across  the  larynx  in  an  antero-posterior  direction, 
about  half  an  inch  below  its  superior  opening  and  a  short  dis- 
tance above  the  true  vocal  cords.  They  are  frequently  very 
prominent,  standing  out  in  thick  welts  from  the  sides  of  the 
larynx.  In  other  instances,  they  can  hardly  be  distinguished 
from  the  surrounding  tissues.  They  are  of  a  deeper  red  color 
than  the  tissues  above  them,  but  their  inferior  or  inner  borders 
generally  appear  pale  in  the  laryngoscopic  image,  on  account 
of  being  illuminated  more  perfectly  than  the  surrounding  parts. 
Just  beneath  the  anterior  ends  of  the  false  vocal  cords  and 
above  the  true  cords  may  frequently  be  seen  a  fossa,  about  the 
size  of  a  pin's  head,  which  has  been  named  by  Mackenzie,  the 


296  THE   THROAT  AND   NASAL   CAVITIES. 

fossa  innominata.  This  communicates  with  the  laryngeal  sinus- 
es upon  either  side. 

VENTRICLES  OF  THE  LARYNX. — Immediately  beneath  the 
ventricular  bands  are  found  the  ventricles  of  the  larynx. 
These  consist  on  either  side  of  an  oblong  fossa,  which  is  the 
opening  to  a  cul-de-sac  of  mucous  membrane,  known  as  the 
sacculus  laryngis.  They  are  bounded  above  by  the  false  vocal 
cords;  below,  by  the  true  vocal  cords;  and  externally,  by  the 
thyro-arytenoid  muscles. 

To  examine  either  side,  the  mirror  should  be  placed  partly 
upon  the  opposite  side  of  the  fauces  with  its  obliquity  changed, 
so  as  to  illuminate  the  parts  to  be  inspected. 


FIG  73. — View  of  left  side  of  larynx  (Tiirck).  a,  left  vocal  cord  ;  i>,  posterior  por- 
tion of  left  ventricle  ;  c,  left  ventricular  band  ;  d,  posterior  surface  of  epiglottis  ;  e, 
border  of  ary-epiglottic  fold  ;  /,  left  cartilage  of  Wrisberg  ;  g,  right  cartilage  of  Wris- 
berg  ;  h,  right  vocal  cord. 

The  ventricles  are  seldom  seen,  and  when  visible,  they 
usually  appear  merely  as  dark  lines ;  but  occasionally  they  are 
patulous,  with  a  width  of  nearly  one  eighth  of  an  inch. 

SACCULUS  LARYNGIS. — The  sacculus  laryngis  extends  up- 
ward and  outward  in  a  conical  form  beneath  the  ventricular 
band.  The  mucous  membrane  lining  it  is  studded  with  the 
openings  of  sixty  or  seventy  follicular  glands,  the  secretion 
from  which  is  apparently  intended  for  lubricating  the  vocal 
cords.  This  pouch  is  covered  by  a  fibrous  membrane  and  this 
membrane  by  muscular  tissue,  which,  according  to  Hilton, 
compresses  the  sacculus  and  discharges  its  secretion  upon  the 
vocal  cords. 

VOCAL  CORDS  AND  GLOTTIS. — The  vocal  cords,  known  also 
as  the  inferior  or  true  vocal  cords,  are  the  most  important  ob- 
jects to  be  seen  on  inspection  of  the  larynx.  They  appear  as 


THE   NORMAL   LARYNX. 

two  pearly  white  bands  stretched  along  either  side  of  the  larynx 
from  its  anterior  to  its  posterior  part.  During  respiration  they 
alternately  approach  each  other  and  recede,  leaving  between 
them  a  triangular  opening  for  the  passage  of  air.  The  cords 
and  the  space  between  them  form  what  is  known  as  the  glottis. 
The  free  edges  of  the  cords  constitute  the  lips  of  the  glottis, 
and  the  chink  or  fissure  between  them  is  called  the  rima  glot- 
tidis.  The  front  of  the  rima  is  formed  by  the  anterior  commis- 
sure of  the  vocal  cords,  its  sides  by  the  cords  themselves,  and 
its  base  by  the  arytenoid  cartilages,  and  the  inter-arytenoid 
fold.  In  the  adult  this  fissure  varies  in  length;  from  seven  to 
ten  lines  in  females,  and  from  ten  to  thirteen  in  males.  At 
its  widest  part  it  ordinarily  measures  from  three  to  six  lines, 
but  in  deep  inspiration  it  may  measure  as  much  as  eight  or  ten 
lines.  In  children,  it  is,  of  course,  much  smaller. 

The  vocal  cords  in  the  adult  vary  from  five  eighths  of  an 
inch  to  one  inch  in  length.  They  are  usually  about  one  eighth 
of  an  inch  in  breadth.  They  are  of  a  bright  white  color,  some- 
times perfectly  white  in  females ;  but  in  males  they  are  usually 
of  a  yellowish-white  hue.  They  consist  of  fibrous  bands  cov- 
ered by  a  thin  layer  of  closely  adherent  mucous  membrane. 
They  are  attached  anteriorly  to  a  depression  between  the  alae 
of  the  thyroid  cartilage,  posteriorly  to  the  anterior  angles  at 
the  base  of  the  arytenoid  cartilages. 


FIG.  74.— Normal  larynx  of  female  in  formation  of  head  tones  (Cohen). 

On  inspiration  the  cords  separate  widely  at  their  posterior 
extremities;  but  their  anterior  extremities  remain  close  to- 
gether, thus  forming  a  triangular  opening.  In  expiration  they 
approach  more  nearly  together,  and  in  phonation  their  two  bor- 
ders are  more  or  less  closely  approximated,  but  they  usually 
gape  slightly  throughout  their  entire  length.  In  females,  and 


298  THE   THROAT   AND   NASAL  CAVITIES. 

occasionally  in  males,  during  the  production  of  head-tones,  the 
vocal  processes  are  pressed  firmly  together,  so  that  the  fissure 
is  left  only  between  the  anterior  parts  of  the  cords. 

PROCESSUS  VOCALES. — The  vocal  processes  are  sometimes 
seen  as  four  yellowish  spots,  two  anteriorly  and  two  posteriorly, 
where  the  vocal  cords  are  attached  to  the  cartilages,  but  the 
anterior  processes  are  not  often  visible.  Usually  when  we 
speak  of  the  vocal  processes  we  refer  simply  to  the  anterior 
angles  of  the  arytenoid  cartilage. 

Dr.  Seiler  has  described  narrow  fusiform  cartilages,  which 
are  found  along  the  edge  of  the  vocal  cords  in  females. 
These  cartilages  are  only  rudimentary  in  males. 

INTER-ARYTENOID  FOLD. — The  inter-arytenoid  fold  or  poste- 
rior commissure  is  a  band  of  mucous  membrane  which  extends 
between  the  arytenoid  cartilages.  The  prominence  of  this  fold 
depends  upon  the  position  of  the  cartilages.  When  the  glottis 
is  open  it  may  measure  three  or  four  lines  in  length,  but  when 
the  cords  are  approximated  to  each  other  it  is  folded  upon 
itself  so  that  it  can  hardly  be  seen. 

CRICOID  CARTILAGE. — The  cricoid  cartilage  may  usually  be 
seen  a  short  distance  below  the  vocal  cords,  separated  from 
their  anterior  extremities  by  the  lower  portion  of  the  thyroid 
cartilage  and  by  the  crico-thyroid  membrane.  This  cartilage 
is  of  a  lighter  hue  than  the  membranous  tissue  above  or  below 
it,  and  is  similar  in  color  to  the  rings  of  the  trachea. 

TRACHEAL  CARTILAGES. — The  rings  of  the  trachea  are  usually 
seen  arching  across  this  tube  from  side  to  side  with  their  con- 
cavities directed  inward  and  downward.  The  upper  of  these 
rings  are  very  distinct  and  of  a  yellowish  or  a  light-pinkish  hue. 
They  are  separated  from  each  other  by  the  intervening  mem- 
branous tissue,  which  is  of  a  darker  color. 

As  we  carry  the  inspection  farther  down  the  trachea,  the 
cartilages  appear  narrower  and  narrower  until  their  outlines 
are  finally  lost. 

The  mucous  membrane  lining  the  trachea  is  generally  paler 
than  that  covering  the  surface  of  the  larynx. 

In  order  to  obtain  a  good  view  of  the  trachea,  it  is  usually 
necessary  to  hold  the  mirror  more  nearly  horizontal  than  in  the 
examination  of  the  larynx,  so  as  to  reflect  the  light  somewhat 
more  posteriorly.  The  glottis  must  be  widely  opened,  and  the 


THE   MAIN   BRONCHI. 


299 


focal  point  of  the  light  must  fall  upon  the  parts  to  be  examined, 
that  is  at  a  distance  of  from  seven  to  eleven  inches  within  the 
lips,  or  from  twelve  to  seventeen  inches  from  the  reflector 
according  to  the  portion  of  the  tube  to  be  examined.  Some' 
times  we  can  obtain  a  good  view  by  elevating  the  patient  to 
a  plane  above  that  of  the  observer  and  holding  the  throat  mir- 
ror almost  horizontal,  so  that  the  light  may  be  thrown  upon 
it  from  below  upward. 

To  expose  the  posterior  wall  of  the  larynx  and  the  trachea, 
the  patient's  head  should  be  kept  erect,  and  the  mirror  must  be 
held  in  a  nearly  horizontal  position. 


Is 


FIG.  75.— View  of  posterior  wall  of  the  FIG.  76. — View  of  anterior  wall  of  tra- 

trachea  and  bronchi,  b  s,  bifurcation  of  chea  and  bronchi,  a  t,  anterior  wall  of 
trachea  ;  s  gt  sub-glottic  region  ;  p,  pos-  trachea  ;  r  vc  and  Ivc,  vocal  cords  ;  rb, 
terior  wall  of  trachea.  (Mackenzie.)  right  bronchus  ;  I  b,  left  bronchus  ;  />  s, 

bifurcation  or  bronchial  spur.     (Macken- 
zie.) 

THE  MAIN  BRONCHI. — With  a  good  light  and  a  favorable 
condition  of  the  larynx  and  trachea,  the  openings  of  the  main 
bronchi  can  frequently  be  seen,  and  in  some  instances  a  few  of 
their  cartilaginous  rings  may  be  counted.  To  illuminate  the 
bifurcation  of  the  trachea,  a  good  plan  is  first  to  obtain  a  view 
of  the  laryngeal  surface  of  the  epiglottis,  and  then,  by  gradu- 
ally changing  the  obliquity  of  the  mirror,  direct  the  rays  farther 
and  farther  downward  along  the  anterior  surface  of  the  trachea 
until  the  deeper  parts  are  brought  into  view. 

This  constitutes  a  description  of  a  typical  larynx,  but  consid- 
erable variety  in  the  shape  and  movements  of  different  parts  of 
this  organ  may  occur  within  the  limits  of  health.  This  is 
especially  the  case  with  the  epiglottis ;  but  variations  in  the 
appearance  of  the  arytenoid  cartilages  and  of  the  commissures, 
and  slight  alterations  in  other  parts  of  the  larynx  may  occ;.- 


300 


THE   THROAT   AND    NASAL   CAVITIES. 


sionally  be  found,  as  illustrated  in  Figs.  67-72  (page  293).  The 
epiglottis  may  possess  any  of  the  various  forms  already  spoken 
of.  The  super-arytenoid  cartilages  vary  considerably  in  their 
size  and  form,  as  already  mentioned.  The  position  of  the  aryte- 
noids  varies  constantly  with  respiration  and  phonation,  and 
may  be  quite  different  in  healthy  individuals  (Figs.  67-72,  page 

293) 

In  disease  of  the  larynx,  changes  in  its  form  and  movements 
constitute  the  principal  signs.  There  may  be  hypertrophy  or 
swelling  of  its  various  parts,  with  more  or  less  loss  of  move- 
ment, or  ulceration  may  have  destroyed  more  or  less  of  the 
tissues.  Sometimes  the  epiglottis  is  so  swollen  and  wrinkled 
as  to  be  hardly  recognizable ;  its  free  edge  may  be  injured  by 
ulceration,  or  it  may  be  partly  or  entirely  destroyed  by  the 
same  process.  Swelling  of  the  inner  extremity  of  the  ary- 
epiglottic  folds  and  of  the  tissues  surrounding  the  arytenoid 
cartilages  is  frequently  found  upon  one  side  or  upon  both  sides. 
Loss  of  movement  occurs  from  cicatricial  adhesions  or  paraly- 
sis. Morbid  growths  are  of  comparatively  frequent  occurrence. 
The  special  changes  caused  by  the  various  diseases  will  be 
mentioned  in  a  subsequent  lecture. 

THE   VAULT  OF   THE  PHARYNX  AND    NASAL    CAVITIES 

IN  HEALTH. 

On  account  of  the  small  size  of  the  mirror,  which  we  are 
generally  obliged  to  use,  and  the  limited  space  through  which 
the  rays  of  light  can  be  reflected,  it  is  impossible  to  obtain 
a  complete  image  of  this  region  in  any  single  position  of  the 
mirror,  but  by  slowly  turning  it  from  side  to  side,  elevating  or 
depressing  the  handle,  and  introducing  the  mirror  first  on  one 
side  of  the  uvula  and  then  the  other,  part  after  part  can  be 
brought  into  view.  We  must  discipline  ourselves  to  combine 
mentally  in  one  whole  the  partial  views  we  are  compelled  to 
take  in  examining  such  small  areas  at  each  view.  Very  few 
students,  or  even  physicians,  are  familiar  with  the  appearance 
of  the  post-nasal  space. 

The  natural  condition  of  these  parts  should  be  thoroughly 
studied  from  diagrams  or  models,  before  an  attempt  is  made 
to  inspect  them  in  the  living  subject,  and  the  student  should 


VAULT   OF   THE   PHARYNX   AND   NASAL  CAVITIES.          3OI 

make  himself  perfectly  familiar  with  the  descriptions  of  dif- 
ferent parts.  When  the  mirror  is  first  carried  into  the  throat 
we  usually  see  in  it  the  image  of  the  upper  surface  of  the  palate' 
or  of  the  posterior  surface  of  the  uvula,  or  of  the  posterior 
wall  of  the  pharynx.  If  either  of  the  first  two  is  brought  into 
view,  we  then  elevate  the  handle  of  the  mirror,  or  if  the  last  is 
seen  we  depress  it,  and  thus  bring  into  the  field  of  vision  the 
parts  just  above  the  soft  palate.  We  then  search  for  the  sep- 
tum narium,  which  is  to  be  taken  as  a  starting  point  for  further 
inspection,  as  the  vocal  cords  are  taken  as  land-marks  in  laryn- 
goscopy. 


FIG.  77. — Rhinoscopic  image,  i,  vomer  or  septum  ;  2,  free  space  of  nasal  passages; 
3,  superior  meatus  ;  4,  middle  meatus  ;  5,  superior  turbinated  bone  ;  6,  middle  turbi- 
nated  bone  ;  7,  inferior  turbinated  bone  ;  8,  pharyngeal  orifice  of  Eustachian  tube  ; 
9,  upper  portion  of  fossa  of  Rosenmueller ;  u,  glandular  tissue  at  the  anterior  portion 
of  the  vault  of  the  pharynx  ;  12,  posterior  surface  of  velum  palati.  (Cohen.) 

Having  found  the  septum,  we  trace  it  throughout  its  entire 
length  from  the  narrow  lower  extremity,  where  it  joins  the 
palate,  to  its  upper  broad  base  which  arches  outward  on  either 
side  at  the  top  of  the  posterior  nares.  On  either  side  of  the 
septum  the  irregular  outer  border  of  the  posterior  opening  of 
the  nasal  cavity  should  be  traced  from  above  downward  past 
the  projecting  turbinated  bones  to  the  orifice  of  the  Eustachian 
tube,  and  finally  to  the  palate  and  lateral  walls  of  the  pharynx. 
The  middle  turbinated  bone  is  the  most  prominent  object  on 
the  outer  border  of  the  nasal  opening;  but  it  seems  overlapped 
at  its  lower  part  by  the  inferior  turbinated  bone. 

External  to  the  middle  turbinated  bone,  and  just  above  that 
portion  of  the  inferior  turbinated  bone  which  seems  to  overlap 
it,  is  a  dark  space  known  as  the  middle  meatus;  and  slightly 
external  to  the  latter  is  the  orifice  of  the  Eustachian  tube. 

Some  physicians,  instead  of  following  this  course  in  their 


CCLLIEGE 
[-  K  V  s  l  c 


302  THE   THROAT   AND   NASAL   CAVITIES. 

inspection,  prefer  to  start  from  the  Eustachian  tube,  but  this  is 
merely  a  matter  of  habit. 

THE  SEPTUM  NARIUM  divides  the  rhinoscopic  view  into 
halves.  It  forms  a  narrow,  shining  column  below,  near  the 
palate,  which  gradually  increases  in  breadth  toward  its  upper 
part.  At  the  lower  part  it  appears  of  a  pinkish,  yellowish,  or 
whitish  color,  according  to  the  brilliancy  of  the  illumination; 
but  toward  the  upper  part  or  base  the  color  deepens  to  a  red 
like  that  of  the  surrounding  mucous  membrane.*  The  sides 
of  the  septum,  a  considerable  portion  of  which  may  be  seen, 
are  usually  of  a  drab  or  ashy-red  color,  slightly  darker  in  hue 
than  the  posterior  edge,  probably  on  account  of  being  less  per- 
fectly lighted.  The  septum  seldom  occupies  exactly  the  centre 
of  the  posterior  nares,  but  inclines  slightly  to  one  side. 

MIDDLE  TURBINATED  BONES. — These  bones  are  easily  found, 
as  they  are  the  most  prominent  objects  in  view  on  the  external 
wall  of  the  nasal  cavity,  of  which  they  seem  to  constitute  the 
greater  part.  They  are  covered  with  a  thin  mucous  membrane 
of  a  pinkish  or  yellowish-white  color.  The  middle  turbinated 
bone  sometimes  resembles  a  mucous  polypus,  for  which  it  may 
be  mistaken  by  the  student. 

INFERIOR  TURBINATED  BONES. — These  lie  just  below  the 
preceding.  They  are  considerably  smaller  than  the  middle 
turbinated  bones,  and  do  not  approach  so  near  the  septum. 
They  are  of  a  darker  color,  probably  from  deficient  illumina- 
tion. Not  infrequently  they  have  the  appearance  of  solid 
tumors. 

THE  EUSTACHIAN  ORIFICE.— The  Eustachian  orifice  on  either 
side  is  found  a  little  external  and  posterior  to  the  inferior  tur- 
binated bone,  usually  on  a  level  with  the  middle  meatus,  but 
sometimes  slightly  above  or  below  it. 

This  opening  has  an  irregularly  triangular  or  crescentic  shape. 
It  usually  measures  about  a  quarter  of  an  inch  in  its  longest 
diameter,  but  it  is  sometimes  large  enough  to  admit  the  tip  of 
the  little  finger.  The  opening  looks  downward,  inward,  and 
slightly  forward  ;  it  is  bounded  by  two  more  or  less  prominent 
projections  called  the  anterior  and  posterior  walls  or  lips  of  the 

*  The  color  of  the  parts,  as  here  described,  is  that  observed  by  means  of  artificial 
light.  Natural  light  gives  a  paler  color. 


4HT 


VAULT   OF   THE   PHARYNX. 


303 


orifice  ;  which  are  covered  with  a  light-red  or  yellowish  mucous 
membrane.  The  former  consists  mainly  of  the  fibres  of  the 
levatpr  palati  muscle,  and  the  latter  of  the  cartilaginous  ex- 
tremity  of  the  Eustachian  tube.  From  the  posterior  or  lower 
lip  a  prominent  ridge,  which  is  formed  by  the  levator  palati 
muscle,  runs  downward  and  inward  to  the  soft  palate.  From 
the  anterior  or  upper  lip  a  dark  groove  runs  upward  and  out- 


FIG.  78. — Adenoid  tissue  at  vault  of 
pharynx.  Posterior  wall  of  upper  part  of 
pharynx  (Luschka).  i-i,  pterygoid  proc- 
ess; 2,  section  of  vomer;  3-3,  posterior 
portion  of  the  vault  of  the  nasal  fossae; 
4-4,  pharyngeal  orifice  of  the  Eustachian 
tube;  5,  orifice  of  the  bursa  pharyngea; 
6-6,  recessus  pharyngeus  (fossa  of  Rosen- 
mueller);  7,  median  folds  formed  by  the 
adenoid  substance  of  the  nasal  portion  of 


FIG.  79. — Pharyngeal  bursa.  Antero- 
posterior  section  (Luschka).  i,  section 
of  basilar  process  of  the  occipital  bone; 
2,  body  of  sphenoid;  3,  pituitary  gland. 
4,  adenoid  substance  of  the  vault  of  the 
pharynx,  behind  which  is  seen,  5,  the 
pharyngeal  bursa. 

N.B. — The  line  from  5  has  accidentally 
been  continued  in  the  cut  beyond  the 
bursa. 


the  pharynx. 

ward  toward  the  vault  and  the  posterior  walls  of  the  pharynx. 
This  groove  is  known  as  the  FOSSA  OF  ROSENMUELLER  or  the 
RECESSUS  PHARYNGEI. 

THE  SUPERIOR  TURBINATED  BONES  are  located  at  the  upper 
part  of  the  nasal  fossse  and  cannot  be  distinctly  seen.  They 
have  the  appearance  of  narrow  triangular  projections,  the  apices 
of  which  point  downward  and  inward.  Their  color  is  dark-red, 
like  that  of  the  base  of  the  septum. 


304  THE   THROAT   AND   NASAL   CAVITIES. 

SUPERIOR,  MIDDLE,  AND  INFERIOR  MEATUS. — These  are  the 
spaces  found  between  the  turbinated  bones  and  the  external  wall 
of  the  nasal  cavity.  The  superior  one  of  these,  which  is  the 
largest,  appears  as  a  large  shadow  at  the  upper  part  of  the 
fossa,  just  below  the  superior  turbinated  bone.  The  middle 
meatus  is  seen  as  a  dark  opening  near  the  middle  part  of  the 
fossa  external  to  the  middle  turbinated  bone.  The  inferior 
meatus,  if  seen  at  all,  generally  appears  simply  as  a  dark  line. 

THE  VAULT  OF  THE  PHARYNX  is  known  also  as  the  fornix 
pharyngis,  and  is  sometimes  spoken  of  as  the  tonsilla  pharyn- 
geus. 

This  is  that  portion  of  the  phary ngeal  wall  which  begins  at  the 
posterior  nasal  orifices  and  extends  backward  along  the  basilar 
process  of  the  occipital  bone,  and  then  downward  to  be  lost  in 
the  posterior  pharyngeal  wall. 

In  the  perspective  view  which  we  obtain  of  this  part  by 
rhinoscopy,  it  appears  shorter  than  natural.  The  mucous 
membrane  is  of  a  light-red  color,  studded  with  minute  whitish 
follicles  and  broken  on  its  surfaces  into  irregular,  more  or  less 
longitudinal  fissures  and  ridges,  which  give  it  much  the 
appearance  of  the  surface  of  the  palatine  tonsil.  This  appear- 
ance of  the  surface  is  caused  by  glandular  tissue  which  has 
received  the  name  of  TONSILLA  PHARYNGEUS.  Near  the  mid- 
dle, at  the  lower  part  of  this  glandular  tissue  is  an  opening 
about  the  size  of  a  pin's  head,  which  leads  up  into  a  small  cul- 
de-sac,  known  as  the  BURSA  PHARYNGEUS.  The  posterior  sur- 
face of  the  uvula,  palate,  and  pillars  of  the  fauces  may  be  seen 
below  the  nasal  fossa.  The  palate  appears  in  the  rhinoscopic 
image  as  a  fleshy  ledge  running  at  right  angles  with  the 
septum. 


LECTURE  XXVII. 

DIAGNOSIS   AND  TREATMENT   OF    DISEASES    OF 

THE   FAUCES. 

ACUTE  SORE  THROAT. 

Synonyms. — Erythematous  or  catarrhal  sore  throat;  Catar- 
rhal  tonsillitis;  Cynanche  pharyngea;  Angina  erythematosa; 
and  Pharyngitis  catarrhalis. 

This  is  a  simple  inflammation  of  the  mucous  membrane  of 
the  palate,  tonsils,  or  phary«x,  or  of  all  of  these  combined.  It 
usually  terminates  in  resolution ;  but  repeated  attacks  'lead  to 
chronic  pharyngitis. 

SYMPTOMS. 

This  affection  is  attended  with  slight  or  considerable  fever, 
dryness,  and  itching  or  pain  of  the  throat.  This  pain  is  often 
acute  and  stinging,  and  radiates  toward  the  ear,  especially  dur- 
ing the  act  of  swallowing. 

There  is  a  tendency  to  hawk  or  hem,  but  cough  is  not  likely 
to  be  present  unless  the  uvula  is  elongated.  Usually  there  is 
some  difficulty  in  articulation,  and  the  voice  has  a  nasal  sound. 
Hoarseness  does  not  appear  until  late  in  the  disease,  when  the 
larynx  has  become  implicated. 

SIGNS. 

Hyperasmia  of  the  mucous  membranes  is  found,  ranging  from 
a  bright-pink  to  a  livid  hue  ;  and  diffused  over  the  entire  throat 
or  limited  to  patches.  In  severer  cases,  there  is  moderate  swell- 
ing of  the  parts  affected.  The  uvula  is  often  swollen  and  elon- 
gated, and  sometimes  the  mucous  membrane  of  the  pharynx, 
on  account  of  its  relaxed  condition,  lies  in  thick  folds. 

DIAGNOSIS. 

The  affection  might  possibly  be  mistaken  for  tonsillitis,  but 
it  is  readily  distinguished  from  the  latter,  after  a  few  hours,  by 
absence  of  any  considerable  amount  of  swelling. 


20 


306  THE   THROAT  AND   NASAL   CAVITIES. 

TREATMENT. 

The  attack  may  often  be  aborted  by  the  same  means  em- 
ployed for  this  purpose  in  acute  or  subacute  laryngitis  or  bron- 
chitis (page  105).  Six  or  eight  drops  of  the  tincture  of  opium, 
taken  in  the  morning  for  its  stimulant  effect,  may  produce  a 
similar  result.  Troches  of  opium  will  give  great  relief,  and 
may  cut  short  the  disease  (Form.  2).  Astringent  troches 
(Form.  25-27),  and  chlorate  of  potassium  are  often  beneficial. 
A  cloth  wet  in  cold  water  and  bound  about  the  neck  on  going 
to  bed  will  frequently  cure  the  affection. 

PHLEGMONOUS   SORE   THROAT. 

Synonyms.  —  Suppurative  pharyngitis;  Acute  tonsillitis; 
Amygdalitis ;  Quinsy;  Angina  tonsillaris,  and  Angina  phleg- 
monosa? 

This  is  a  severer  form  of  inflammation  than  simple  sore 
throat,  and  is  characterized  by  inflammation,  not  only  of  the 
mucous  membrane,  but  also  of  the  submucous  tissues  of  the 
palate,  base  of  the  tongue,  tonsils,  epiglottis,  and  sometimes 
the  fibrous  sheaths  of  the  muscles.  As  a  result,  the  tissues  be- 
come infiltrated  with  serum,  and  finally  a  circumscribed  or 
diffused  abscess  occurs. 

SYMPTOMS. 

The  affection  usually  begins  with  a  rigor,  which  is  followed 
after  a  few  hours  by  marked  fever,  pain,  dryness,  a  persistent 
sense  of  constriction  in  the  throat  and  painful  deglutition. 

SIGNS. 

\ 

All  the  structures  of  the  throat,  but  especially  the  tonsils,  are 
congested,  swollen,  and  sensitive.  The  tonsils  may  be  so 
swollen  as  to  reach  the  median  line.  If  both  are  involved  there 
may  be  danger  of  suffocation. 

DIAGNOSIS. 

The  physical  appearances  and  the  acute  character  of  the 
attack,  and  the  absence  of  certain  other  diseases,  as,  for  example, 
scarlatina,  will  render  the  diagnosis  easy. 

TREATMENT. 

Locally. — Early  in  the  attack  it  may  sometimes  be  cut  short 


ERYSIPELATOUS   SORE   THROAT. 

by  brushing  the  parts  with  a  strong  solution  of  nitrate  of  silver, 
grs.  xl.  or  Ix.  to  the  ounce  of  distilled  water.  Inhalation  of 
steam  from  water  alone,  or  impregnated  with  such  sedatives  as 
watery  extract  of  opium  or  of  belladonna,  lupuline,  and  com- 
pound tincture  of  benzoin  (Form.  35-40)  will  often  afford  relief. 
Warm  cataplasms  are  also  useful.  Scarification  of  the  parts  is 
often  followed  by  good  results. 

When  pus  forms  it  should  be  evacuated  at  once. 

Internally. — Early  we  get  good  results  from  the  use  of  small 
and  repeated  doses  of  aconite.  Later,  saline  laxatives  should  be 
given  to  keep  the  bowels  soluble.  These  may  be  supplemented 
with  quinine,  gr.  ii.,  and  chlorate  of  potassium,  gr.  v.  or  x., 
every  three  hours,  with  anodynes  when  necessary. 

ERYSIPELATOUS   SORE   THROAT. 

This  is  a  comparatively  rare  affection.  When  it  does  occur 
it  is  usually  associated  with  facial  erysipelas. 

SYMPTOMS. 

I 

The  principal  symptoms  are  stinging  pain,  heat  and  dryness 
of  the  throat;  high  fever,  and  usually  nausea  and  pain  in  the 
epigastrium.  Dyspnoea  and  more  or  less  difficulty  in  swallow- 
ing are  usually  present.  If  there  be  much  oedema,  there  may 
also  be  regurgitation  of  fluid  through  the  nose,  accompanied 

by  choking. 

SIGNS. 

By  inspection  we  observe  diffused  dusky  or  purplish  redness 
of  the  throat ;  which  sometimes  has  a  dry  shining  appearance. 
Occasionally  vesicles  are  seen,  and  ordinarily  there  .is  moderate 

swelling. 

DIAGNOSIS. 

This  must  rest  mainly  on  the  presence  of  external  erysipelas. 

TREATMENT. 

The  remedies  to  be  employed  are  essentially  the  same  as  for 
erysipelas  of  the  skin.  Quinine  and  tincture  of  iron  are  gener- 
ally recommended.  If  gangrene  occurs,  gargles  of  chlorate  or 
permanganate  of  potassium  or  of  carbolic  acid  should  be  em- 
ployed. If  oedema  of  the  glottis  takes  place,  scarification  and, 
in  some  cases,  tracheotomy  should  be  practiced. 


THE   THROAT   AND   NASAL   CAVITIES. 


RHEUMATIC   SORE   THROAT. 

This  is  a  form  of  acute  sore  throat,  occurring  in  persons  of  a 
rheumatic  diathesis,  which  is  attended  with  severe  local  and 
constitutional  symptoms. 

These  are  :  high  temperature,  rapid  pulse,  and  aching  pains  in 
the  neck,  back,  and  limbs. 

The  local  affection  may  pass  off  with  rheumatic  affection  of 
the  muscles,  or  it  may  be  followed  by  articular  rheumatism. 

DIAGNOSIS. 

The  physical  appearances  are  not  different  from  those  of 
simple  catarrhal  sore  throat ;  therefore  the  diagnosis  must  rest 
upon  a  history  of  previous  similar  attacks,  the  severe  symp- 
toms, and  the  supervention  of  rheumatic  pains  in  the  muscles 
or  joints. 

TREATMENT. 

Internally. — We  may  employ  salicylic  acid,  grains  x.,  every 
hour  until  sweating  occurs,  and  subsequently  less  frequently, 
for  twenty-four  or  thirty-six  hours.  Guaiacum  in  full  doses  is 
more  effectual  in  other  cases. 

The  common  alkalies  or  iodide  of  potassium  should  be  given 
later,  and  in  some  cases  they  answer  well  from  the  first. 
Locally  sedative  applications  and  guaiac  lozenges  are  indicated 
(Form.  30). 

SIMPLE   MEMBRANOUS   SORE   THROAT. 

Synonyms. — Herpetic  sore  throat;  Aphthous  sore  throat; 
Angina  membranacea  ;  Herpes  pharyngis  ;  Herpes  gutteralis. 

This  form  of  sore  throat  ordinarily  results  from  exposure  to 
cold,  and  is  characterized  by  the  formation  of  small  blisters  or 
herpetic  patches,  the  exudation  from  which  soon  forms  a  sort 
of  false  membrane,  similar  to  that  which  often  covers  herpetic 
eruptions  on  the  lips. 

SYMPTOMS. 

The  affection  is  usually  ushered  in  with  a  chill,  followed  by 
more  or  less  fever,  and  dryness,  smarting,  and  pain  in  the  throat. 


ACUTE   FOLLICULAR   PHARYNGITIS. 

The  symptoms  usually  increase  in  severity  for  a  short  time, 
and  high  fever  may  supervene. 

SIONS. 

The  affection  usually  involves  one  tonsil  only,  but  it  may 
spread  over  the  palate  and  affect  both  sides,  and  occasionally 
it  attacks  the  posterior  wall  of  the  pharynx. 

If  the  throat  is  examined  early,  a  few  small  yellowish-white 
vesicles  will  be  seen,  isolated  or  gathered  in  patches  and  sur- 
rounded by  congested  areolas.  These  may  disappear  in  a 
couple  of  days  without  farther  signs ;  but  usually  the  vesicles 
rupture  in  a  few  hours,  leaving  an  excoriated  surface  which 
soon  becomes  covered  with  a  yellowish-white  pultaceous  mem- 
brane. This  membrane  can  be  easily  removed,  and  the  excori- 
ated surface  exposed.  Two  or  three  days  later,  if  the  membrane 
is  displaced,  the  mucous  membrane  appears  natural,  the  excori- 
ation having  healed. 

DIAGNOSIS. 

This  affection  is  very  likely  to  be  mistaken  for  diphtheria. 
If  seen  in  the  vesicular  stage,  the  error  will  not  be  made ;  but 
if  the  patient  does  not  come  under  observation  until  two  or 
three  days  later,  the  diagnosis  may  be  very  difficult  or  even 
impossible,  especially  if  diphtheria  is  prevalent  at  the  same 
time.  However,  in  most  cases  the  membrane  in  herpetic  sore 
throat  is  thinner  and  more  easily  detached  than  in  diphtheria, 
and  the  constitutional  disturbance  is  much  less. 

In  some  cases  an  herpetic  eruption  on  the  lips  will  at  once 
reveal  the  true  nature  of  the  disease. 

TREATMENT. 

Internally,  quinine  in  moderate  doses  is  indicated,  with  a 
mild  laxative,  and  small  doses  of  Dover's  powder  when  there  is 
much  pain.  Locally. — Good  effects  are  often  obtained  from  a 
gargle  of  chlorate  of  potassium ;  some  of  which  may  be  swal- 
lowed with  advantage.  Hydrastin  in  powder,  sedative  and 
astringent  lozenges,  or  astringent  sprays  and  gargles  are  useful 
(Form.  61-65  and  12-14). 

ACUTE   FOLLICULAR  PHARYNGITIS. 
This  affection  is  described  by  Mackenzie  as  one  of  the  forms, 
of  herpetic  pharyngitis ;  but  as  the  inflammation  is  confined  to 


THE   THROAT   AND   NASAL   CAVITIES. 

the  same  tissues  as  the  chronic  exudative  follicular  pharyngitis, 
I  think  its  consideration,  under  the  above  name,  more  likely  to 
lead  to  prompt  recognition  of.  the  disease.  It  consists  of  an 
acute  inflammation  of  the  follicles,  in  the  mucous  membrane,  on 
the  posterior  pharyngeal  wall.  The  distended  follicles  finally 
rupture,  and  small  ulcers  occur,  which  ordinarily  heal  in  a  few 
days. 

SYMPTOMS. 

The  common  symptoms  are  high  fever,  soreness  of  the  throat, 
and  intense  pain  on  attempting  to  swallow. 

SIGNS. 

On  inspecting  the  pharynx  early  in  the  disease,  a  number  of 
inflamed  follicles  are  seen  blocked  with  their  own  secretions 
and  having  the  appearance  of  pustules.  If  the  case  is  seen  a 
little  later,  the  membrane  covering  these  follicles  will  have 
given  way,  the  secretions  will  have  escaped,  and  a  small  round 
ulcer  will  remain. 

DIAGNOSIS. 

The  acute  history  and  the  appearances  just  described  render 
an  error  in  diagnosis  almost  impossible.  However,  in  not  a 
few  instances,  the  seat  of  the  difficulty  will  be  overlooked 
unless  the  laryngoscopic  mirror  be  used,  for  the  inflammation 
may  be  confined  to  the  follicles  in  the  lower  part  of  the  phar- 
ynx where  they  cannot  be  seen  by  ordinary  inspection. 

TREATMENT. 

Internally. — I  would  recommend  saline  laxatives,  quinine  in 
tonic  doses,  and  chlorate  of  potassium  in  doses  of  grs.  v.  to  xv. 
four  times  a  day,  if  it  does  not  cause  too  much  smarting.  Ano- 
dynes should  be  given  if  necessary. 

Locally. — Morphia  and  carbolic  acid  (Form.  91)  may  be 
applied  with  a  brush,  and  followed  in  a  few  minutes  with  a  simi- 
lar application  of  nitrate  of  silver,  gr.  Ix.  ad  fl.  ^  i.  of  distilled 
water.  The  former  application  relieves  the  pain,  and  prevents 
much  of  the  pain  which  would  otherwise  be  caused  by  the 
caustic  solution.  The  latter  usually  cures  the  disease  promptly; 
but  the  application  may  need  to  be  repeated  daily  for  a  few  days. 
At  first,  sedative  lozenges  are  useful  for  a  few  days.  Later, 


CHRONIC   FOLLICULAR   PHARYNGITIS.  31 1 

lozenges  of  an  astringent  or  stimulating  character  are  more 
beneficial  (Form.  21-31). 


ACUTE  FOLLICULAR  GLOSSITIS. 

This  affection  is  like  the  preceding,  excepting  that  the  in- 
flamed follicles  are  located  on  one  or  both  sides  of  the  base  of 
the  tongue. 

SYMPTOMS. 

There  is  acute  pain  in  swallowing  which  is  referred  princi- 
pally to  the  ear  or  to  a  position  corresponding  to  the  inner 
orifice  of  the  Eustachian  tube.  The  inflamed  follicles  cannot 
be  seen  without  the  throat  mirror;  and  even  with  it  they  nre 
very  apt  to  be  overlooked,  the  physician  supposing  the  cause 
of  the  trouble  to  be  in  the  posterior  nares,  or  deeper  in  the 
pharynx. 

DIAGNOSIS. 

*  During  the  first  or  second  days  of  the  disease,  careful  inspec- 
tion of  the  sides  of  the  base  of  the  tongue  reveals  a  number  of 
white  or  yellowish-white  elevated  follicles.  If  the  case  is  seen 
later,  these  will  have  ulcerated,  and  the  ulcers  may  have  coa- 
lesced so  as  to  cover  a  large  surface.  A  thorough  inspection 
will  at  once  settle  the  question  of  diagnosis. 

TREATMENT. 

I  have  always  found  one  or  two  applications  of  a  sixty-grain 
solution  of  nitrate  of  silver  sufficient  to  effect  a  cure. 

CHRONIC  FOLLICULAR  PHARYNGITIS. 

Synonyms. — Clergyman's  sore  throat ;  Chronic  catarrhal  sore 
throat ;  Chronic  pharyngitis  ;  Granular  pharyngitis ;  Glandular 
pharyngitis;  Chronic  catarrhal  pharyngitis;  Ulcerated  sore 
throat,  and  improperly,  Herpetic  pharyngitis. 

This  is  a  chronic  inflammation  of  the  pharynx,  mostly  limited 
to  the  follicles;  which  are  hypertrophied,  and  appear  as  ele- 
vated granular  bodies,  or  which  may  be  filled  with  a  whiti 
secretion  that  causes  them  to  appear  as  pustules. 

The  affection  is  caused  by  derangements  of  the  dige 
organs,  the  inordinate  use  of  spices  and  hot  drinks,  and 


THE   THROAT   AND   NASAL   CAVITIES. 

exposure  to  cold ;  but  it  is  most  frequently  excited  by  im- 
proper use  of  the  voice  in  the  open  air  or  in  poorly  ventilated 
halls,  or  during  an  acute  inflammation. 

SYMPTOMS. 

The  most  prominent  symptoms  are  :  slight  discomfort  in  the 
throat,  with  some  hoarseness  and  a  little  pain  after  using  the 
voice  for  a  short  time.  Hearing  is  frequently  impaired  from 
inflammation  of  the  mucous  lining  of  the  Eustachian  tube,  or 
from  collections  in  its  orifice  of  the  secretions  from  the  pharynx. 
Pain  on  swallowing  is  not  uncommon.  There  is  a  frequent 
desire  to  hawk  and  clear  the  throat. 

SIGNS. 

The  mucous  membrane  of  the  fauces  may  be  uniformly  con- 
gested ;  or  the  hyperaemia  may  be  confined  to  the  pillars  of  the 


FIG.  80. — Chronic  follicular  pharyngitis.     (Cohen.) 

fauces,  to  the  base  of  the  posterior  pillars,  or  to  patches  of  the 
posterior  pharyngeal  wall. 

Here  and  there  enlarged  blood-vessels  may  be  seen.  The 
follicles  usually  stand  out  like  large  red  granulations  sur- 
rounded with  a  congested  areola,  or  as  yellowish  semi-trans- 
parent prominences  closely  resembling  small  blisters.  In  other 
instances  the  follicles,  from  being  distended  with  their  desic- 
cated secretions,  appear  like  pustules.  Finally,  ulceration  of  the 
follicles  may  occur,  leaving  small  round  excavations,  which  by 
extension  may  coalesce  with  others  and  thus  form  a  large 


CHRONIC  FOLLICULAR   PHARYNGITIS.  ,,- 

irregular  superficial  ulcer.  The  mucous  membrane  is  usually 
partially  covered  with  mucus  or  small  masses  of  greenish  or 
yellowish  muco-pus. 

In  some  cases,  termed  Pharyngitis  Sicca,  the  mucous  mem- 
brane is  atrophied,  and  has  an  abnormally  dry  or  glazed 
appearance. 

DIAGNOSIS. 

Unless  ulceration  has  taken  place,  the  affection  is  not  likely 
to  be  confounded  with  other  diseases ;  but  when  ulcers  are 
present  it  may  be  mistaken  for  secondary  syphilis  or  acute 
tuberculous  pharyngitis.  In  such  cases  the  diagnosis  must 
rest  largely  on  the  history  and  concomitant  constitutional 
symptoms. 

Acute  tuberculosis  of  the  throat  is  attended  with  grave  consti- 
tutional symptoms  and  signs  of  pulmonary  disease,  which  do 
not  occur  in  this  affection. 

Secondary  syphilis  can  generally  be  traced  to  a  primary  sore. 
The  ulcers  are  preceded  by  mucous  patches,  and  are  often 
found  in  the  anterior  portion  of  the  mouth,  or  arranged  sym- 
metrically on  both  sides  of  the  mouth,  which  is  not  the  case 
with  the  ulcers  in  chronic  catarrhal  sore  throat. 

TREATMENT. 

The  first  indication  in  this  as  in  other  diseases  is  to  remove 
the  cause,  if  possible;  or,  if  it  has  already  disappeared,  to  re- 
move the  conditions  which  favor  the  continuance  of  the  disease. 

In  this  affection,  we  should  attend  first  to  the  condition  of 
the  digestive  organs,  for  which  saline  laxatives  and  bitter  tonics 
are  often  necessary.  A  combination  of  quinine,  gr.  i.,  arsenious 
acid,  gr.  ^5-,  and  extract  of  nux  vomica,  gr.  |,  in  pill  form,  to  be 
taken  three  times  a  day,  is  very  beneficial.  Alcoholic  stimu- 
lants, hot  drinks,  highly  spiced  foods,  and  tobacco  should  be 
interdicted. 

Locally. — Krameria  or  guaiac  lozenges  are  useful  (Form.  25 
and  30).  Sprays  of  chloride  of  ammonium,  chlorate  of  potas- 
sium, or  sulphate  of  zinc,  in  weak  solutions,  may  be  beneficially 
applied  two  or  three  times  daily  by  the  patient.  If  these  fail, 
strong  solutions  of  mineral  astringents  should  be  applied  by 
the  brush.  When  there  is  much  thickening,  a  solution  of 
iodine,  gr.  xxx.,  to  glycerine,  3  i.,  may  be  painted  on  the  parts 


THE   THROAT   AND   NASAL   CAVITIES. 

with  good  effects.  Where  the  parts  are  irritable,  a  good  appli- 
cation consists  of  iodoform  in  solution  in  chloroform  or  ether, 
gr.  xxx.  to  3  i.,  or  the  same  in  powder,  diluted  with  one  or 
two  parts  of  acacia,  and  applied  with  the  insufflator.  In  mild 
cases,  when  the  mucous  membrane  is  not  irritable,  I  have  found 
the  best  results  from  a  powder  of  hydrastin  (Form.  1 10),  which 
should  be  thrown  into  the  vault  of  the  pharynx  by  an  insuffla- 
tor. The  application  should  be  repeated  in  two  or  three  days, 
or  as  soon  as  the  effects  of  the  first  have  entirely  subsided. 
Lennox  Browne  recommends  destroying  the  large  blood-ves- 
sels which  may  be  seen  in  the  mucous  membrane  of  the  pharynx 
by  means  of  the  galvano-cautery.  with  which  they  may  be 
burned  across ;  or  by  cutting  across  them  with  a  sharp  lancet, 
and  then  pressing  a  pointed  piece  of  caustic  for  a  few  seconds 
into  the  cut.  Mackenzie  destroys  hypertrophied  follicles  with 
London  paste.  When  the  follicles  are  blocked  up  with  secre- 
tions, he  scrapes  the  mucous  membrane  covering  them  with  a 
curette,  empties  the  cavity  of  the  follicle,  and  then  touches  it 
with  a  pointed  stick  of  nitrate  of  silver. 

SCROFULOUS   SORE   THROAT. 

This  is  a  disease  of  childhood  which  is  characterized  in  a 
mild  form  by  the  physical  appearances  found  in  simple  chronic 
sore  throat,  and  in  a  severe  form  by  ulcerations  which  can- 
not be  distinguished  from  those  found  in  debilitated  subjects, 
whether  of  tuberculous,  syphilitic,  rheumatic,  or  arthritic  ori- 
gin. Dr.  Cohen  inclines  to  the  opinion  that  these  are  com- 
mon sore  throats  in  subjects  of  a  latent  inherited  syphilitic 
taint. 

DIAGNOSIS. 

There  are  no  positive  symptoms  or  signs  which  can  enable 
us  to  differentiate  the  severe  form  from  syphilitic  ulceration, 
and  it  is  hardly  fair  to  base  our  diagnosis  on  the  effects  of  treat- 
ment; because  some  cases,  clearly  syphilitic,  are  not  benefited 
by  specific  treatment,  and  others  not  of  specific  origin  are 
promptly  relieved  by  iodide  of  potassium.  The  disease  bears 
some  resembles  to  tuberculous  sore  throat. 

TREATMENT. 

The  treatment  is  principally  that  indicated  for  the  constitu- 


ACUTE   TUBERCULOUS   SORE   THROAT.  •„* 

tional  cause.  Local  stimulants  and  alteratives,  especially  iodine, 
sometimes  prove  beneficial.  Astringent  and  stimulating  lozen- 
ges will  be  useful  in  some  cases. 


ACUTE  TUBERCULOUS  SORE  THROAT. 

This  is  an  acute  miliary  tuberculosis  of  the  throat,  which  runs 
a  rapid  course,  and  terminates  fatally  in  from  eight  to  twenty- 
four  weeks,  on  account  of  the  attending  pulmonic  disease. 

It  is  characterized  by  the  constitutional  symptoms  of  tuber- 
culosis, and  in  the  early  stage,  locally,  by  abundant  gray  gran- 
ulations, of  small  size,  beneath  the  epithelium.  These  granula- 
tions are  usually  grouped  in  patches.  They  bleed  easily  when 
touched,  and,  if  very  abundant  and  prominent,  closely  resemble 
the  mucous  patches  of  syphilis,  but  they  lack  the  inflammatory 
areola  of  the  latter.  These  granulations  are  located  on  the 
palate,  palatine  folds,  and  pharynx.  Late  in  the  disease  they 
are  found  on  the  epiglottis  and  in  the  larynx.  As  the  disease 
progresses  they  increase  in  size,  lose  their  transparency,  and 
become  hidden  by  a  purulent  pultaceous  covering.  Finally 
superficial  ulceration  occurs. 

SYMPTOMS. 

We  find  intense  local  pain,  and  dysphagia  increasing  as  the 
disease  advances,  with  persistent  fever. 

SIGNS. 

Inspection  reveals  the  presence  of  the  granulations  just  men- 
tioned, usually  associated  with  superficial  ulceration. 
ulcers  are  small  and  of  lenticular  shape,  unless  several  ulcers 
have  coalesced,  and  are  covered  with  a  grayish,  pultaceous 
muco-pus.  Their  borders  are  not  well  defined,  there  being  no 
distinct  line  of  demarcation,  and  no  surrounding  inflamed 
areola. 

DIFFERENTIAL  DIAGNOSIS. 

The  disease  is  liable  to  be  mistaken  for  syphilitic  or  scrofu- 
lous sore  throat.     The  differential  features  are  shown  i 
following  tables  : 


3i6t 


THE   THROAT   AND   NASAL   CAVITIES. 


ACUTE  TUBERCULOUS  SORE  THROAT.  SYPHILITIC  SORE  THROAT. 

Symptoms  and  Signs. 

Much  pain,  marked  febrile  symptoms,  Slight   pain.      Febrile   symptoms   are 

especially  in  the  evening.  slight. 

Inspection. 

Early,  numerous  small   gray  granula-  Early,  larger  elevated   mucous  tuber- 

tions,  surrounded  by  a  pale  mucous  mem-  cles,  which  do  not  bleed  when  touched, 
brane.  These  bleed  easily.  Later,  and  which  are  surrounded  by  a  congested 
ulcerations  small  and  comparatively  su-  areola.  Later,  ulcers,  which  if  superfi- 
perficial.  cial,  as  in  secondary  syphilis,  are  large  ; 

and  which,  if  small,  as  in  tertiary  syph- 
ilis, are  deep. 

ACUTE  TUBERCULOUS  SORE  THROAT.  SCROFULOUS  SORE  THROAT. 

Symptoms  and  Signs. 
Usually  occurs  in  young  adults.  Usually  occurs  in  children  under  ten 

years  of  age. 

Marked  febrile  reaction.  No  fever. 

Edges  of  ulcer  not  distinct.  Edges  of  ulcer  well  defined,  everted 

and  cord-like. 

Ulceration  superficial,  but  moderately  Ulceration  more  likely  to  involve  the 

active.  deeper    structures,   but  very  slow  in  its 

progress. 

TREATMENT. 

Anodynes,  when  required  to  relieve  pain,  are  to  be  admin- 
istered. Sedative  lozenges  will  give  considerable  comfort. 
Whiskey,  cod-liver  oil  and  chloride  of  calcium  may  be  given 
for  their  constitutional  effects,  but  unfortunately  we  can  do 
very  little  for  these  cases. 


LECTURE  XXVIII. 
DISEASES   OF   THE   FAUCES— Continued. 

SYPHILITIC   SORE   THROAT. 

Syphilis  may  affect  the  fauces  in  any  one  of  its  three  stages, 
but  the  primary  manifestations  are  seldom  seen  in  the  throat. 
The  symptoms  and  signs  of  this  affection  vary  according  to  the 
stage  in  which  they  appear. 

SYMPTOMS  AND  SIGNS. 

Primary  syphilis  affecting  the  fauces  causes  no  symptoms, 
unless  the  chancre  assumes  a  phagedenic  form,  in  which  case 
it  is  likely  to  cause  pain  and  febrile  symptoms.  Physical  ex- 
amination may  reveal  a  superficial  ulcer  or  chancre,  surrounded 
by  a  zone  of  swollen  mucous  membrane,  and  resting  on  an  in- 
durated base,  as  may  be  determined  by  the  touch. 

Phagedenic  ulcers  have  a  dirty  grayish  floor,  and  for  a  few 
days  they  extend  rapidly. 

These  lesions  are  seldom  observed,  and  when  found  they  are 
very  apt  to  be  misinterpreted. 

Secondary  syphilis  of  the  fauces  is  indicated  by  hyperaemia  or 
mucous  patches.  The  former  usually  causes  a  red  band  along  the 
border  of  the  soft  palate  and  symmetrical  erythematous  patches 
on  the  sides  of  the  mouth.  The  latter,  known  also  as  mucous 
tubercles  or  broad  condylomata,  are  usually  arranged  symmet- 
rically on  each  side  of  the  throat.  They  have  a  circular  or 
elliptic  form,  a  pale  surface,  and  are  slightly  elevated  above  the 
surrounding  tissues,  which  are  of  a  bright-red  color.  Later, 
these  patches  are  the  seat  of  superficial  ulcerations  which  have 
a  grayish-white  surface  and  uneven  borders.  These  ulcers 
usually  cause  considerable  soreness. 

When  secondary  syphilitic  manifestations  are  of  hereditary 
origin,  they  usually  occur  in  the  upper  part  of  the  pharynx  or 
on  the  fauces  soon  after  birth. 

Tertiary  syphilis  in  the  fauces  is  accompanied  by  superficial 


THE   THROAT   AND   NASAL   CAVITIES. 

or  deep  ulcerations,  or  by  gummata.  The  former  most  fre- 
quently appear  on  the  palate  or  pillars  of  the  fauces  and 
spread  rapidly  to  the  surrounding-  mucous  membrane.  They 
are  usually  bathed  in  an  unhealthy  secretion.  If  this  is  re- 
moved by  a  bit  of  sponge  or  absorbent  cotton,  the  base  of  the 
ulcer  is  found  to  be  pale  and  smooth,  or  studded  here  and  there 
Avith  fungous  granulations.  These  ulcers  have  an  irregular  out- 
line with  serrated  edges,  from  which  fissures  sometimes  extend 
a  considerable  distance  into  the  surrounding  mucous  mem- 
brane. 

The  deep  ulcers  are  not  so  large  as  the  superficial,  but  they 
may  involve  all  the  deeper  structures,  affecting  alike  cartilage 
or  bone.  These  ulcers  usually  appear  first  as  a  red  spot,  which 
soon  acquires  a  whitish  hue,  due  to  the  formation  of  a  little 
abscess;  this  is  shortly  followed  by  perforation  of  the  mucous 
membrane,  and  discharge  of  an  ichorous  pus. 

From  this  time  ulceration  steadily  progresses.  It  invades 
the  deeper  tissues  more  rapidly  than  the  surrounding  mucous 
membrane,  and  thus  undermines  the  edges  of  the  ulcer. 

Usually  patients  in  this  condition  suffer  little  or  no  pain,  but 
the  constitutional  affection  may  cause  serious  loss  of  appetite, 
emaciation,  and  hectic  fever,  and  may  finally  prove  fatal. 

Syphilitic  gummata  in  the  throat  usually  appear  beneath  the 
mucous  membrane  of  the  posterior  part  of  the  pharynx,  but 
occasionally  they  are  seen  in  the  palate.  They  are  observed, 
at  first,  as  slight  elevations  which  gradually  increase  in  size 
and  finally  ulcerate,  unless  arrested  by  treatment.  At  first  the 
mucous  membrane  covering  these  nodules  is  not  affected,  but 
after  a  time  it  becomes  congested. 

When  these  gummy  tumors  are  situated  in  the  palate,  perfo- 
ration is  likely  to  occur,  which  gives  the  voice  a  nasal  quality. 
This  accident  also  causes  the  patient  great  inconvenience  by 
allowing  fluids  or  particles  of  food  to  escape  from  the  mouth 
into  the  nasal  cavity. 

Tertiary  syphilis  of  the  throat,  when  hereditary,  usually 
makes  its  appearance  between  the  third  and  the  fifteenth  year, 
and  causes  ulcerations  of  the  palate ;  these  may  heal,  only  to 
recur  again  and  again. 

Ulcerations  of  the  posterior  pharyngeal  wall  and  of  the  soft 


DIPHTHERIA. 
> 

palate  are  often  followed  by  cicatricial  adhesions  of  the  eroded 
surfaces,  with  consequent  pharyngeal  stenosis. 

DIAGNOSIS. 

Primary  syphilis  of  the  throat  presents  no  characteristic 
appearances  and  can  seldom  be  detected,  except  when  a  sus- 
picious sore  is  coupled  with  a  suspicious  history ;  and  even  then 
the  occurrence  of  secondary  signs  is  often  necessary  before  a 
positive  diagnosis  can  be  made. 

The  characteristic  mucous  tubercles  or  patches  of  the  secon- 
dary stage,  when  associated  with  a  syphilitic  history,  cannot  be 
mistaken. 

Tertiary  ulceration  might  be  mistaken  for  cancer  or  tubercu- 
lous ulceration. 

Cancer  is  usually  attended  with  more  pain  and  thickening  in 
the  parts  than  syphilis.  It  also  has  a  brighter  redness  of  the 
mucous  membrane  and  there  is  less  destruction  of  the  tissues. 

Tuberculous  ulceration  causes  more  pain  and  the  ulcers  are 
smaller  than  the  syphilitic  sores. 

TREATMENT. 

Internally. — The  constitutional  treatment  for  syphilis  is  of 
prime  importance  after  the  primary  stage. 

Locally. — Phagedenic  chancres  should  be  cauterized  with  a 
solution  of  sulphate  of  copper,  gr.  xv.-fl.  §  i.,  with  acid  nitrate 
of  mercury,  full  strength,  or  diluted  with  from  one  to  six  parts 
of  water,  or  with  the  galvano-cautery.  Tertiary  ulcerations 
may  be  treated  in  the  same  manner.  Hypersemic  patches  of 
the  secondary  stage  may  be  brushed  with  a  solution  of  chloride 
of  zinc,  gr.  xxx.-fl.  ?  i.  Mucous  patches  of  this  stage  are 
best  treated  by  the  local  application  of  tincture  of  iodine  or 
solid  nitrate  of  silver. 


DIPHTHERIA. 

This  is  a  constitutional  affection,  the  consideration  of  which 
more  properly  belongs  to  works  on  general  diseases ;  but  as  it 
is  attended  by  marked  local  manifestations  which  may  be  mis- 


THE   THROAT   AND   NASAL   CAVITIES. 

taken  for  those  of  membranous  croup*  or  simple  membranous 
sore  throat,  I  will  refer  to  it  briefly. 

The  affection  is  characterized  by  great  prostration,  intense 
fever,  and  the  formation  of  a  dirty  grayish  or  brownish  false 
membrane. 

This  membrane  rests  on  an  ulcerated  surface,  and  is  most 
frequently  seen  on  the  mucous  membrane  of  the  fauces,  but 
sometimes  it  is  found  in  the  larynx  and  nasal  cavities. 

DIAGNOSIS. 

The  characteristic  membrane  on  the  uvula  and  behind  it 
removes  from  the  category  of  diseases,  which  are  likely  to  be 
confounded  with  it,  everything  excepting  true  croup  and  mem- 
branous sore  throat.  The  differential  features  of  these  will  be 
pointed  out  when  we  consider  the  latter  affections. 

TREATMENT. 

Supporting  and  stimulating  treatment  is  indicated  from  the 
first,  viz.,  quinine  and  tincture  of  iron  in  moderate  doses  fre- 
quently repeated,  and  alcoholic  stimulants  in  abundance.  Ja- 
borandi,  or  its  active  principle  pilocarpine,  has  of  late  been 
highly  recommended,  but  I  have  not  observed  any  permanent 
effect  from  its  use. 

Locally. — When  the  patient  does  not  resist,  the  false  mem- 
brane should  be  pencilled  two  or  three  times  a  day  with  a 
strong  solution  of  persulphate  or  pernitrate  of  iron.  Good 
effects  are  also  obtained  from  the  use  of  a  solution  of  benzoate 
of  soda  thrown  into  the  throat  by  means  of  an  ordinary  steam 
atomizer  every  two  or  three  hours,  about  one  fluid  ounce  of  the 
solution  being  used  each  time  (Form.  68  and  72).  Lactic  acid, 
gr.  xx.-fl.  §  i.  of  water,  may  be  used  in  the  same  manner. 


ACUTE   TONSILLITIS. 

Synonyms.  —  Amygdalitis  ;  Cynanche  tonsillaris  ;  Quinsy; 
Acute  inflammation  of  the  tonsil. 

This  affection  consists  of  an  acute  inflammation  of  the  paren- 
chymatous  portion  of  the  tonsil,  which  may  be  general,  or  con- 

*  This  is  thought  by  many  to  be  identical  with  diphtheria. 


ACUTE   TONSILLITIS.  32I 

fined  to  a  few  follicles.  Inflammation  of  the  mucous  covering 
of  the  gland  is  often  included  in  this  term,  but  it  is  more 
appropriately  considered  under  the  head  of  acute  catarrhal 
sore  throat.  When  the  follicles  alone  are  affected,  the  disease 
is  often  termed  FOLLICULAR  TONSILLITIS. 

The  affection  is  usually  excited  by  exposure  to  cold  or  wet. 
It  is  most  commonly  met  with  in  individuals  subject  to  rheu- 
matic or  herpetic  attacks. 

SYMPTOMS. 

Excepting  in  mild  cases,  there  is  high  fever  with  a  quick 
pulse,  hot  skin,  headache,  aching  of  the  back  and  limbs.  The 
patient  has  a  sensation  of  dryness  and  stiffness  in  the  throat, 
with  pain  radiating  toward  the  ears,  and  exaggerated  by  swal- 
lowing. The  senses  of  hearing,  taste,  and  smell  are  more  or 
less  interfered  with  ;  and  if  both  tonsils  are  affected,  dyspnoea 
may  become  urgent  with  its  attendant  symptoms.  Fluids  are 
often  regurgitated  through  the  nose  on  attempts  at  swallow- 
ing.  The  voice  is  weak  and  nasal. 

SIGNS. 

The  tonsil  is  red  and  swollen,  so  that  it  may  project  beyond 
the  median  line.  In  the  follicular  variety,  its  surface  is  studded 
with  numerous  yellowish-white  spots,  due  to  collection  of  the 
follicular  secretions  beneath  the  mucous  membrane.  The  palate 
and  uvula  are  generally  congested  and  swollen,  and  the  latter 
is  elongated,  and  often  seen  sticking  to  one  of  the  tonsils. 


DIAGNOSIS. 


Inspection  'of  the  throat  usually  settles  the  diagnosis  at  once, 
but  sometimes  it  will  be  necessary  to  watch  the  case  for  a  day 
or  two  before  we  can  exclude  scarlatina  or  diphtheria. 

TREATMENT. 

Guaiacum  lozenges,  containing  three  grains  each,  and  taken 
every  two  hours,  will  seldom  fail  to  check  the  disease  if  taken 
early  (Form.  30).  The  ammoniated  tincture  of  guaiacum  may 
be  used  for  the  same  purpose,  or  the  same  result  may  be 
obtained  by  painting  the  inflamed  part  with  a  solution  of 
nitrate  of  silver,  gr.  lx.-  3  i.  At  first,  small  doses  of  aconite, 
frequently  repeated,  moderate  the  fever.  Anodynes  and  cata- 
plasms soothe  the  pain.  Tonics  are  indicated.  The  bowels 
should  be  kept  soluble. 


21 


322  THE    THROAT   AND   NASAL   CAVITIES. 


CHRONIC   TONSILLITIS. 

Synonyms. — Hypertrophy  of  the  tonsils  ;  Enlarged  tonsils. 

This  consists  of  chronic  inflammation  with  an  increase  in  the 
constituent  structures  of  the  gland.  It  is  sometimes  congenital, 
but  it  generally  results  from  repeated  acute  inflammations, 
diphtheria,  or  the  strumous  diathesis. 

It  is  frequently  developed  about  the  age  of  puberty,  and  in 
such  instances  it  is  supposed  to  be  due  to  some  sympathetic 
connection  with  the  sexual  organs.  The  permanent  interference 
with  respiration,  caused  by  this  affection,  impairs  the  general 
health,  and  in  proportion  to  the  obstruction  renders  the  patient 
liable  to  disease,  especially  of  the  respiratory  organs. 

SYMPTOMS. 

We  notice  difficulty  in  respiration,  causing  noisy  breathing, 
and  snoring  during  sleep.  The  interference  with  nasal  respira- 
tion causes  the  patient  to  breathe  through  the  mouth,  which  is 
therefore  kept  partly  open.  The  constitutional  effects  of  con- 
tinued imperfect  respiration  often  give  the  individual  a  dull  or 
stupid  expression. 

The  swelling,  by  encroaching  on  the  nasal  cavities  and  ori- 
fices of  the  Eustachian  tubes,  causes  thickness  of  the  voice  and 

partial  deafness. 

SIGNS. 

The  surface  of  the  tonsil  has  a  granular  appearance,  and  is 
not  infrequently  honeycombed  by  the  dilated  lacunas.  The  en- 
largement, which  may  vary  from  the  size  of  a  filbert  to  that  of 
a  walnut,  is  at  once  seen  on  inspecting  the  fauces.  According 
to  Lambron,*  the  obstruction  to  respiration  causes  a  circular 
depression  of  the  chest  at  the  junction  of  its  middle  third  with 
the  lower  third.  This  gives  an  appearance  of  abnormal  bulg- 
ing at  the  upper  part  of  the  thorax. 

DIAGNOSIS. 
No  difficulty  will  be  experienced  in  diagnosis. 

TREATMENT. 

The  sizs  of  the  tonsil  mav  be  slightly  reduced  by  local  as. 

*  Mackenzie's  Diseases  of  the  Throat  and  Nose. 


'CONCRETIONS   IN   THE   TONSIL. 


tringent  or  stimulating  applications  ;  but  the  process  is  tedious 
and  generally  inefficient  if  the  glandular  structure  is  hyper- 
trophied. 

Injection  into  the  growth  of  a  few  drops  of  a  solution  of 
iodine  or  of  ergotine,  by  means  of  a  hypodermic  syringe,  will 
so  netimes  reduce  the  size  of  the  gland.  Caustics  or  electrol- 


S»kRP  8.  SUVttt  CWCKUO 


o 


FIG.  81. — Charriere's  amygdalotome,  with  fenestra  at  right  angles  to  handle. 

8 


A 
FIG.  82. — The  same,  fenestra  placed  obliquely. 

ysis  may  be  effectually  employed,  but  excision  is  the  speediest 
and  usually  the  most  satisfactory  remedy.  The  general  health 
should  be  improved  by  tonics,  alteratives,  and  nutritive  diet. 


CONCRETIONS   IN   THE   TONSIL. 

Synonyms. — Foreign  bodies  or  calculi  in  the  tonsils. 

Calculi  in  the  tonsils  result  from  blocking-up  of  the  lacunae 
and  retention  of  the  altered  secretions  of  the  follicles,  which 
finally  become  inspissated  and  calcareous. 

SYMPTOMS. 

Usually  a  slight  pricking  sensation  is  present.  If  the  calculi 
are  numerous  or  large,  there  is  more  or  less  dysphagia.  The 
concretions  frequently  predispose  to  repeated  attacks  of  quinsy. 

DIAGNOSIS. 

The  diagnosis  can  only  be  made  with  accuracy  when  the 
calculus  protrudes,  is  expelled,  or  can  be  felt  with  the  finger  or 

with  the  probe. 

TREATMENT. 

The  rational  course  is  to  remove  the  calculus.  If  the  tonsil 
is  much  enlarged  it  must  be  excised. 


THE   THROAT   AND   NASAL   CAVITIES. 


FOREIGN   BODIES   IN   THE   FAUCES. 

Foreign    bodies   which   become   lodged   in   the   tonsil    and 
pharynx  are  discovered  by  inspection,  and  require  removal. 


RETRO-PHARYNGEAL   ABSCESS. 

This  consists  of  a  collection  of  pus  in  the  cellular  tissue  be- 
neath the  pharyngeal  mucous  membrane.  It  is  a  comparatively 
rare  affection,  usually  dependent  upon  acute  pharyngitis, 
specific  fevers,  or  disease  of  the  cervical  vertebrae. 

SYMPTOMS. 

Deep-seated  pain  in  the  pharynx,  with  dysphagia,  dyspnoea, 
and  dysphonia  are  complained  of. 

SIGNS. 

When  located  high  in  the  pharynx,  the  swelling  may  be  seen 
on  simple  inspection.  If  deeper  seated  it  may  be  seen  with  the 
laryngoscope,  or  felt  with  the  finger. 

DIFFERENTIAL  DIAGNOSIS. 

This  affection  may  be  mistaken  for  oedema  of  the  larynx  or 
for  croup.  Laryngoscopic  inspection,  when  possible,  will  at 
once  establish  the  diagnosis.  In  young  children,  palpation 
with  the  finger  introduced  into  the  throat  will  usually  answer 
the  same  purpose. 

(Edema  of  the  Larynx. — In  this  affection  lifting  the  larynx  by 
external  manipulation  does  not  relieve  the  dyspnoea  as  it  does 
in  retro-pharyngeal  abscess. 

Croup. — In  croup  the  voice  is  soon  lost  instead  of  being  sim- 
ply altered,  and  there  is  no  dysphagia,  as  in  retro-pharyngeal 
abscess. 

,       TREATMENT. 

Until  pus  forms,  sucking  bits  of  ice  or  its  external  application 
are  the  best  remedies.  As  soon  as  pus  collects  it  should  be 
evacuated  by  a  free  incision.  The  head  should  be  thrown 
promptly  forward  as  soon  as  the  incision  is  made,  to  prevent 
the  matter  from  running  into  the  larynx.  Supporting  measures 
and  tonics  are  also  indicated. 


NEUROSES  OF  THE  PHARYNX. 


NEUROSES  OF  THE  PHARYNX. 

These  affections  may  involve  either  the  nerves  of  sensation 
or  of  motion.  They  may  result  either  from  central  or  periph- 
eral lesions  or  irritations. 

ANESTHESIA. 

Anaesthesia  of  the  pharynx  is  rarely  met  with.  When  it  does 
occur  it  is  principally  of  importance  as  an  early  sign  in  some 
cases  of  progressive  bulbar  paralysis. 

TREATMENT. 

We  must  rely  mainly  on  strychnia  and  galvanism,  but  in 
most  cases  we  cannot  hope  for  a  cure. 


HYPERESTHESIA. 

Hyperaesthesia  of  the  pharynx  is  of  frequent  occurrence.  It 
almost  always  attends  acute  inflammations,  and  it  constitutes 
one  of  the  principal  obstacles  to  laryngoscopic  examinations. 

TREATMENT. 

Sedative  applications  are  useful  to  relieve  pain,  but  farther 
than  this  no  treatment  will  be  required  other  than  that  for  the 
disease  with  which  it  may  be  associated.  Of  the  sedative 
applications  recommended  in  the  Appendix,  those  for  use  by 
the  steam  atomizer  will  be  specially  beneficial  when  acute 
inflammation  exists. 

PAR^STHESIA. 

Morbid  sensations  in  the  throat  may  occur  in  hysterical 
women  without  any  special  exciting  cause,  but  they  most  fre- 
quently follow  the  removal  of  foreign  bodies.  These  are  usually 
pricking  or  scratching  sensations,  which  are  sometimes  felt 
for  months  after  the  offending  substance  has  been  removed. 

TREATMENT. 

When  the  parsesthesia  is  due  to  a  small  ulcer  caused  by  a 
foreign  substance,  it  is  generally  relieved  by  a  few  applications 


326  THE   THROAT   AND   NASAL  CAVITIES. 

of  a  mild  caustic  or  of  a  strong  astringent.     When  it  is  due 
to  hysteria,  treatment  should  be  directed  to  the  latter  disease. 


NEURALGIA. 

This  is  a  rare  affection  of  the  throat,  which  has  not  been 
thoroughly  described. 

TREATMENT. 

Anti-neuralgic  remedies  are  indicated  internally.  Mackenzie 
has  found  the  greatest  benefit  from  brushing  the  parts  three  or 
four  times  a  day  with  tincture  of  aconite  root. 

SPASM. 

Spasm  of  the  pharynx  is  so  rarely  observed  as  to  need  no 
special  description. 

The  neuroses  of  sensation  which  have  just  been  described 
are  usually  recognized  without  difficulty. 

\ 

PARALYSIS. 

There  are  four  varieties  of  paralysis  of  the  palate  and  phar- 
ynx. "  First.  The  affection  which  is  a  frequent  sequel  of 
diphtheria  and  occasionally  met  with  after  common  angina. 
Second.  Slight  paralysis  which  is  sometimes  associated  with 
facial  paralysis.  Third.  Paralysis  of  the  constrictors  of  the 
pharynx,  which  is  always  associated  with  a  similar  condition  of 
the  cesophageal  muscles.  Fourth.  The  loss  of  power,  which  is 
one  of  the  most  marked  phenomena  of  progressive  bulbar 
paralysis."  * 

DIPHTHERITIC  PARALYSIS  of  the  fauces  usually  makes  its 
appearance  in  from  ten  to  fifteen  days  after  convalescence  from 
diphtheria.  It  may  terminate  in  recovery  or  end  in  general 
paralysis,  or  in  paralysis  of  the  heart. 

SYMPTOMS  AND  SIGNS. 

The  patient  first  notices  some  difficulty  in  swallowing  fluids 
which  may  regurgitate  into  the  nostrils,  or  which  owing  to 
paralysis  of  the  depressors  of  the  epiglottis,  may  flow  into  the 

*  Mackenzie,  Diseases  of  the  Throat  and  Nose. 


NEUROSES  OF  THE  PHARYNX. 

larynx  and  cause  paroxysms  of  suffocation  and  cough.  Prick- 
ing sensations  are  sometimes  noticed  in  the  parts.  The  voice 
acquires  a  nasal  twang,  and  there  is  an  inability  to  articulate 
certain  nasal  sounds.  The  power  of  expectoration  may  be 
lost.  The  sense  of  taste  is  somewhat  obtunded.  The  palate  is 
seen  to  hang  loosely,  and  the  patient  is  unable,  to  elevate  it;  or 
one  side  may  be  completely  paralyzed,  and  the  muscles  of  the 
other  side  may  retain  their  power  wholly  or  but  partially.  , 

TREATMENT. 

Tonics,  strychnia,  and  electricity  are  indicated.  Semi-solid 
foods  should  be  given.  Fluids  must  be  prohibited  or  admin- 
istered through  a  stomach  tube,  or  per  rectum,  in  order  to 
avoid  the  evil  consequences  which  would  follow  their  accidental 
passage  into  the  larynx. 

In  the  second  variety  of  paralysis,  the  uvula  usually  deviates 
to  the  healthy  side  and  scarcely  moves  in  phonation.  No 
special  treatment  is  required. 

PARALYSIS  OF  THE  CONSTRICTORS  OF  THE  PHARYNX.— The 
third  variety  is  characterized  by  dysphagia ;  swallowing  being 
accomplished  slowly,  and  most  easily  in  the  erect  position. 
Solids  are  swallowed  more  easily  than  fluids  and  large  boluses 
with  less  difficulty  than  small  particles.  Usually  saliva  flows 
constantly  from  the  mouth  in  consequence  of  the  difficulty  in 

swallowing. 

DIAGNOSIS. 

The  diagnosis  must  be  made  from  the  symptoms  just  enu- 
merated. 

TREATMENT. 

Strychnia  should  be  given  for  its  tonic  effects.  In  marked 
cases  foods  must  be  introduced  through  a  stomach  tube  or  per 
rectum.  Electricity  is  sometimes  useful,  sometimes  hurtful, 
and  sometimes  even  dangerous. 

PROGRESSIVE  BULBAR   PARALYSIS.— The  fourth   variety  • 
paralysis  of  the  pharynx  is  the  most  characteristic  phenomenon 
of  the  so-called  progressive  bulbar  paralysis.     This  is  ust 
the  first  manifestation  of  general  progressive  paralysi 
structural  lesion  of  the  medulla  oblongata. 

SYMPTOMS. 

This  affection  is  characterized  by  difficulty  in  mastication  and 


THE   THROAT   AND   NASAL   CAVITIES. 

by  dysphagia.  There  is  also  an  inability  to  pronounce  the 
labials,  as  b,  w,  m,  p,  f,  or  the  dentals,  as  /,  d,  n,  ch.  Dysp- 
noea is  always  present.  Fluids  regurgitate  through  the  nostrils 
in  attempted  deglutition.  There  is  an  inability  to  retain  the 
saliva.  The  voice  becomes  nasal  and  finally  aphonic.  With 
the  further  progress  of  the  disease,  the  respiratory  muscles  be- 
come involved  and  finally  death  terminates  the  patient's  miser- 
able existence. 

DIAGNOSIS. 

The  diagnosis  is  based  upon  the  history  of  the  case,  the 
foregoing  symptoms,  and  the  physical  evidences  of  paralysis  in 
the  muscles  of  the  lips,  tongue,  palate,  pharynx,  and  larynx. 

TREATMENT. 

The  physician's  efforts  should  be  directed  mainly  to  pro- 
moting the  patient's  comfort.  Strychnia  and  galvanism  have 
been  recommended,  but  no  treatment  has  as  yet  been  found 
curative. 


SWALLOWING  OF  THE  TONGUE  (So  Called). 

This  is  an  extremely  rare  accident.  Most  of  the  cases  seem 
to  have  occurred  in  children  suffering  from  whooping  cough. 
A  case  which  I  reported  to  the  American  Laryngological 
Society  at  its  annual  meeting,  1880,  occurred  in  a  lady  suffer- 
ing from  hysteria.  It  was  characterized  by  a  spasmodic  action 
of  the  hyo-glossus  and  probably  also  the  stylo-glossus  muscles; 
which  drew  the  tongue  into  the  pharynx  in  such  a  position  as 
to  prevent  respiration.  There  was  no  cough. 

TREATMENT. 

The  tongue  should  be  drawn  forward  to  prevent  suffocation. 
Subsequently  the  primary  disease  should  receive  appropriate 
treatment. 

DISEASES  OF  THE  VALECUL^;  AND  PYR1FORM  SINUSES. 

These  sinuses  are  liable  to  ulceration  from  the  irritation  set 
up  by  foreign  bodies,  as  bits  of  food,  or  from  inflammation  of 
the  muciparous  glands. 


DISEASES   OF   THE   VALECUL^E   AND   PYRIFORM  SINUSES.     329 
SYMPTOMS  AND  SIGNS. 

Ulcerations  of  the  pyriform  sinus  cause  cough,  and  pricking 
sensations  with  pain,  especially  on  swallowing,  and  frequently 
hoarseness.  Ulcerations  of  the  valeculse  cause  similar  pricking 
sensations  and  more  or  less  pain.  Upon  a  laryngoscopic  exam- 
ination,  the  sinus  is  usually  found  partially  filled  with  mucus. 
When  this  is  removed  by  a  bit  of  sponge,  the  ulcerated  surface 
or  the  foreign  body  which  has  caused  the  disturbance  will  be 
brought  into  view  and  the  diagnosis  settled. 

TREATMENT. 

Foreign  bodies  should  be  removed  with  forceps.  Ulcers 
usually  heal  promptly  under  the  influence  of  topical  applica- 
tions of  nitrate  of  silver  in  strong  solutions. 


LECTURE    XXIX. 
DISEASES   OF  THE   LARYNX. 

SIMPLE   ACUTE   LARYNGITIS. 

Synonyms. — Acute  catarrhal  laryngitis  ;  Cynanche  laryngea ; 
Angina  laryngea ;  Angina  epiglottidea ;  Inflammation  of  the 
larynx. 

This  consists  of  a  simple  inflammation  of  the  mucous  mem- 
brane of  the  larynx,  frequently  with  more  or  less  implication 
of  the  submucous  tissues.  In  children,  resolution  generally 
occurs,  and  no  sequelae  are  left ;  but  in  adults  the  disease  may 
pass  into  a  chronic  form  of  inflammation,  or  it  may  cause  fatal 
oedema  of  the  larynx. 

SYMPTOMS. 

1 

It  is  characterized  by  dyspnoea,  dysphonia  or  aphonia,  strid- 
ulous  breathing,  cough,  and  pain.  When  not  of  traumatic 
origin  this  affection  usually  approaches  insidiously,  preceded 
by  a  slight  coryza,  subacute  laryngitis  or  bronchitis,  and  finally 
it  is  ushered  in  with  a  slight  chill,  followed  by  fever. 

The  patient  complains  of  roughness  or  tickling  in  the  throat, 
with  a  scratching  or  burning  pain  aggravated  by  coughing  or 
speaking,  together  with  a  constant  disposition  to  cough,  dry- 
ness  and  constriction  of  the  throat,  and  some  difficulty  in 
swallowing. 

In  severe  cases  all  these  symptoms  are  aggravated.  There 
is  a  sense  as  of  a  foreign  body  in  the  larynx,  with  spasm  of  the 
glottis  and  great  dyspnoea,  which  causes  the  patient  to  clutch 
at  the  bed-clothes  or  surrounding  objects,  in  his  efforts  at  in- 
spiration. 

At  first  the  countenance  is  flushed  and  the  eye  bright,  but  as 
obstruction  at  the  glottis  increases,  there  is  anxiety  in  the  ex- 
pression, with  congestion  and  cyanosis  of  the  countenance, 
lividity  of  the  lips,  and  an  ashy  pallor  of  the  skin.  The  eye- 


SIMPLE  ACUTE   LARYNGITIS.  33I 

balls  protrude  and  are  surrounded  by  a  dark  halo.  The  pulse, 
which  at  first  was  full  and  bounding,  now  becomes  weak,  rapid, 
and  irregular.  The  voice,  which  was  hoarse  and  hollow  or 
shrill,  is  emitted  with  considerable  difficulty  or  with  actual 
pain,  and  becomes  feeble  and  may  finally  be  lost.  Respiration 
is  labored  in  proportion  to  the  narrowing  of  the  glottis. 

At  first  the  dyspnoea  is  not  present  except  when  the  patient 
is  agitated,  and  it  is  hardly  ever  very  marked  in  children, 
though  in  the  adult  it  may  be  more  distressing.  Finally,  in 
severe  cases,  the  arms  are  fixed,  the  head  raised,  and  the  chest 
heaves  in  violent  efforts  at  respiration;  the  inspiratory  act, 
which  at  first  was  wheezing  and  slightly  increased  in  length, 
ultimately  becomes  stridulous  and  greatly  prolonged.  The 
respirations  are  diminished  in  frequency,  and  finally  gradual 
asphyxia  or  sudden  spasm  of  the  glottis  may  terminate  the 
case.  Sometimes  the  patient  dies  in  a  comatose  condition,  from 
carbonic-acid  poisoning. 

The  cough  is  painful  and  convulsive.  At  first  it  is  clear  and 
shrill,  but  later  it  becomes  hoarse,  hollow,  or  brazen,  like  the 
cough  of  croup.  Finally,  in  severe  cases,  the  movements  of 
coughing  may  be  observed  without  any  sound  being  produced. 
The  laryngeal  secretion  is  tenacious,  consisting  usually  of  small 
pellets  of  glairy  mucus,  often  streaked  with  blood.  These  are 
thrown  out  with  great  difficulty.  In  favorable  cases  the  secre- 
tions become  more  abundant,  and  of  a  muco-purulent  character. 
As  the  inflammation  progresses,  all  the  symptoms  of  the  early 
part  of  the  disease  become  more  and  more  aggravated. 

SIGNS. 

Upon  laryngoscopic  examination,  in  mild  cases,  we  observe 
bright-red  hypersemia,  with  occasionally  enlarged  blood-vessels 
coursing  over  the  epiglottis  or  vocal  cords.  In  some  cases  an 
effusion  of  serum  beneath  the  mucous  membrane  speedily 
oceurs,  causing  transparent  oedematous  swelling,  which  more 
or  less  encroaches  upon  the  opening  of  the  larynx  (Fig.  86). 
When  the  epiglottis  is  much  inflamed,  it  is  enlarged  and  pend- 
ent, so  as  greatly  to  interfere  with  inspection  of  the  lower 
parts  of  the  larynx,  and  its  laryngeal  surface  cannot  be  seen. 
When  the  ary-epiglottic  folds  are  inflamed,  they  become  very 
irregular  in  outline,  and  greatly  swollen.  The  ventricular 


332  THE    THROAT   AND   NASAL   CAVITIES. 

bands  are  sometimes  highly  turgid  and  protrude  so  as  to  hide 
the  vocal  cords,  only  a  small  portion  of  the  posterior  part  of 
which  can  be  seen  during  phonation.  When  the  vocal  cords 
are  inflamed,  they  are  slightly  swollen  and  of  a  bright-red  color, 
especially  at  their  posterior  extremities. 

When  considerable  dysphonia  exists,  gaping  of  the  glottis  is 
ordinarily  observed,  due  to  paresis  of  the  vocal  cords.  In 
other  cases,  the  gaping  is  confined  to  the  posterior  part  of  the 
glottis,  and  is  due  to  paralysis  of  the  arytenoideus.  In  still 
other  instances,  there  is  bulging  of  the  central  portions  of  the 
cords,  with  gaping  anteriorly  and  posteriorly  (Fig.  120,  page 
388).  Occasionally  small  erosions,  which  leave  no  cicatrices 
on  healing,  are  seen  on  the  surface  of  the  mucous  membrane, 
most  frequently  along  the  lip  of  the  epiglottis. 

DIAGNOSIS. 

A  combination  of  the  symptoms  already  mentioned  with 
these  physical  appearances  leaves  no  room  for  doubt  as  to  the 
diagnosis ;  but  the  disease  is  liable  to  be  mistaken,  by  those  who 
depend  on  symptoms  alone,  for  laryngismus  stridulus,  mem- 
branous croup,  chronic  laryngitis,  or  paralysis  of  the  laryngeal 
muscles. 

Laryngismus  Stridulus. — Acute  laryngitis  may  be  distin- 
guished from  laryngismus  stridulus  by  its  different  history 
and  by  the  laryngoscopic  appearances. 

Acute  laryngitis  is  usually  preceded  by  slight  catarrh,  and  is 
ushered  in  by  chills  and  fever.  Upon  inspection  the  larynx- 
presents  the  signs  of  active  inflammation  of  the  mucous  mem- 
brane. Laryngismus  stridulus  is  sudden  in  its  accession,  being 
preceded  by  no  chill  or  fever,  and  it  is  not  attended  by  inflam- 
mation. In  children  under  five  or  six  years  of  age  it  is  very 
difficult,  if  not  impossible,  to  make  a  laryngoscopic  examina- 
tion, but  in  older  children  inspection  may  generally  be  accom- 
plished by  tact  and  patience. 

Croup. — In  young  children  the  diagnosis  between  laryngitis 
and  croup  will  have  to  rest  upon  the  history  and  symptoms. 
In  those  who  are  older  a  laryngoscopic  examination  determines 
the  nature  of  the  disease  at  once,  unless  a  case  of  croup  should 
happen  to  be  seen  before  exudation  has  taken  place.  The  dif- 
ferential features  between  these  two  diseases  are  shown  in  the 
following  table : 


SIMPLE  A;UTE  LARYNGITIS. 

ACUTE  LARYNGITIS.  MEMBRANOUS  CROUP. 

Attack  preceded  by  slight  catarrh,  and  Accession  is  gradual,  febrile  symptoms 

ushered  in  with  a  chill  and  fever.  slight. 

Frequently  pain  in  the  larynx.  Little  or  no  pain. 

Respirations  quick  and  sonorous,  but  Respirations  slow  and  labored,  with 

usually  no  marked  dyspnoea  in  children.  great  dyspnoea. 

Cough  painful  and  paroxysmal,  but  not  Cough  croupy,  i.  e.,  metallic,  brazen, 

necessarily  croupy.  or  shrill. 

Sputum  scanty,  tenacious,  and  glairy  ;  Sputum  characteristic  if  it  contains 

but  not  characteristic.  shreds  or  lumps  of  false  membrane. 

No  exudation  of  inflammatory  lymph  False  membrane  sometimes  found  in 

in  the  fauces  or  larynx.  the  fauces,  and  always  in  the  larynx. 

The  disease  is  distinguished  by  the  history  from  simple 
chronic,  or  tuberculous,  or  syphilitic  laryngitis. 

Paralysis  of  the  Vocal  Cords. — It  is  distinguished  from  paraly- 
sis of  the  vocal  cords  by  the  history  and  by  the  physical  appear- 
ances. The  neurotic  affections  are  usually  sudden  in  their 
accession,  and  they  cause  no  hypersemia  of  the  parts. 

TREATMENT. 

At  first  we  can  often  abort  the  attack  by  administering  ten 
grains  of  Dover's  powder.  Small  doses  of  aconite  (Form,  i) 
may  be  given,  together  with  sedative  vapors  or  inhalations  of 
opium,  belladonna,  benzoin,  or  lupulin  (Form.  36-40),  and  seda- 
tive troches  (Form.  21-24).  Large  doses  of  bromide  of  potas- 
sium and  the  belladonna  vapors  are  especially  useful  if  there 
is  much  tendency  to  spasm  of  the  glottis.  Saline  laxatives  are 
generally  useful.  Hot  compresses  or  poultices  to  the  throat 
are  very  beneficial.  A  moist  atmosphere  of  uniform  tempera- 
ture should  be  secured.  The  use  of  the  voice  should  be  re- 
stricted. The  use  of  tobacco  must  be  interdicted. 

Late  in  the  affection  astringent  and  stimulant  inhalations  and 
pigments  are  very  useful  (Form.  47-52  and  94-98).  Stimulant 
and  astringent  troches  are  also  beneficial,  but  they  do  harm 
early  in  the  attack. 

In  children  it  is  well  to  commence  the  treatment  with  a 
calomel  purge,  and  to  follow  it  with  the  same  treatment  recom- 
mended for  croup.  If  cedema  supervenes,  an  attempt  should 
be  made  to  relieve  it  by  the  internal  administration  of  full 
doses  of  jaborandi.  If  this  fails,  scarification  of  the  swollen 
parts  or  rupturing  the  mucous  membrane  with  the  finger,  must 
be  practiced  ;  or  if  both  of  these  are  impracticable  or  unsuc- 


334  THE   THROAT   AND   NASAL  CAVITIES. 

cessful,  tracheotomy  must  be  performed  as  soon  as  dyspnoea 
becomes  urgent.  For  several  weeks  after  an  attack  great  care 
should  be  taken  to  prevent  a  recurrence  of  the  disease. 

SUBACUTE    LARYNGITIS. 

Subacute  laryngitis  consists  of  congestion  or  mild  inflamma- 
tion of  the  laryngeal  mucous  membrane.  It  is  far  more  com- 
mon  than  acute  laryngitis,  and  it  is  nearly  always  present  in 
what  is  known  as  a  common  cold. 

SYMPTOMS. 

The  symptoms  are  tickling  with  slight  pain  and  dryness  of 
the  throat  and  inclination  to  cough,  with  hoarseness  but  little 
or  no  fever.  All  of  these  symptoms  vary  according  to  the 
congestion  or  swelling  of  the  vocal  cords ;  they  are  usually 
slight  as  compared  with  those  of  acute  laryngitis.  The  cough 
is  hacking  and  laryngeal,  and  the  expectorated  matter  consists 
of  a  small  amount  of  glairy  mucus. 

SIGNS. 

Upon  inspection  of  the  larynx,  we  find  congestion  with  slight 
oedema,  especially  at  the  posterior  part  of  the  vocal  cords. 
There  can  be  no  difficulty  in  making  a  diagnosis. 

TREATMENT. 

The  milder  measures  recommended  for  acute  laryngitis  should 
be  resorted  to  first.  Troches  containing  borax  or  chloride  of 
ammonium  are  often  useful. 

TRAUMATIC   LARYNGITIS. 

Traumatic  laryngitis  may  result  from  the  irritation  caused 
by  foreign  bodies,  from  the  inhalation  of  irritating  gases,  or 
from  mechanical  injury  in  operations;  but  most  commonly  it 
occurs^in  children  from  swallowing  boiling  liquids  or  inhaling- 
steam,  as  for  example,  in  attempting  to  drink  from  a  tea 
kettle. 

SYMPTOMS. 

After  this  accident  the  inflammation  comes  on  almost  instan 
taneously,  with  acute  pain,  and  oedema  of  the  epiglottis  and 
deeper  portions  of  the  larynx  which  causes  great  dyspnoea. 


CHRONIC   LARYNGITIS.  --- 

SIGNS. 

The  tongue  and  throat  are  red  and  angry,  or  white  from 
detachment  of  the  epithelial  layer  of  the  mucous  membrane  or 
from  plastic  exudation.  The  oedematous  epiglottis  can  often 
be  seen  standing  up  behind  the  base  of  the  tongue,  without  the 
aid  of  the  laryngoscope.  It  is  seldom  possible  to  make  a  laryn- 
goscopic  examination. 

DIAGNOSIS. 

The  diagnosis  will  be  easily  made  from  the  history  and  from 
the  appearance  of  the  mouth  and  fauces. 

TREATMENT. 

The  affection  can  sometimes  be  aborted  by  painting  the  parts 
with  a  strong  solution  of  nitrate  of  silver.  However,  this 
application  is  not  devoid  of  danger  from  spasm  of  the  glottis. 
Full  doses  of  jaborandi  may  be  tried.  Constant  applications 
of  ice  to  the  neck,  and  sucking  of  ice,  should  be  practiced ;  or 
in  its  stead  hot  applications  or  inhalations  of  steam.  The  parts 
usually  become  oedematous  in  spite  of  these  measures,  and  then 
scarification  or  tracheotomy  must  be  promptly  performed. 


CHRONIC   LARYNGITIS. 

Synonyms. — Laryngitis  chronica;  Chronic  catarrh  of  the 
larynx. 

This  affection  is  characterized  by  hoarseness  or  loss  of  voice, 
and  more  or  less  cough,  with  frequent  inclination  to  clear  the 
throat.  It  sometimes  follows  acute  laryngitis  or  repeated 
attacks  of  the  subacute  affection,  but  more  often  it  comes  on 
independently. 

SYMPTOMS. 

We  usually  find  that  the  patient,  otherwise  in  good  health, 
has  noticed  for  some  time  a  sense  of  something  wrong  in  the 
throat.  There  has  been  occasionally  hoarseness  and  dryness, 
especially  after  slight  exposure  to  cold,  and  now  and  then  he 
has  expectorated  little  pellets  of  glairy  viscid  mucus.  Some- 
times  he  is  suddenly  awakened  by  a  sense  of  suffocation,  as 
though  something  had  fallen  into  the  larynx.  This  feeling, 
however,  is  readily  relieved  by  swallowing  saliva  or  water. 


336  THE   THROAT   AND   NASAL  CAVITIES. 

A  somewhat  peculiar  form  of  laryngitis,  attended  with  more  or  less  hoarseness  and 
other  symptoms  attributable  to  the  throat  and  larynx,  often  occurs  in  persons  from 
twenty  to  thirty  years  of  age.  Generally  the  sensations  are  not  marked,  but  often  there 
js  tickling  in  the  throat  and  sometimes  pain,  which  is  occasionally  aggravated  by 
deglutition  or  phonation.  There  is  also  frequent  desire  to  clear  the  throat,  due  to  the 
congestion  and  altered  secretions. 

In  mild  cases  there  are  generally  no  constitutional  symptoms, 
but  occasionally  fever,  night-sweats,  and  emaciation  may  be 
observed. 

In  protracted  or  severe  cases,  especially  those  attended  with 
considerable  cough  or  with  ulceration,  the  constitutional  symp- 
toms become  marked.  There  are  hectic  fever,  night-sweats, 
broken  rest,  emaciation,  and  in  some  instances  dysphagia  or 
absolute  inability  to  swallow  either  fluids  or  solids  on  account 
of  the  pain. 

Impairment  of  the  voice,  varying  in  degree  from  slight 
hoarseness  to  complete  aphonia,  is  a  most  common  symptom. 
In  the  incipient  stages  of  the  disease  the  hoarseness  is  usually 
worse  early  in  the  morning  or  after  resting  or  eating.  The 
voice  improves  by  use,  owing  to  quickened  capillary  circula- 
tion and  stimulation  of  the  nerves.  Sometime^  the  voice  is 
clear  in  ordinary  tones,  and  discordant  only  under  exertion,  as 
in  singing  or  shouting.  In  other  instances  the  hoarseness  is  less 
marked  in  singing  or  shouting  than  in  ordinary  conversation. 

Respiration  is  not  affected. 

The  cough  usually  consists  of  a  slight  hawk  or  hem  ;  but  it  is 
sometimes  frequent  and  very  troublesome,  especially  at  night, 
so  as  to  interfere  with  the  patient's  rest.  The  expectoration  is 
scanty,  a  great  deal  of  cough  being  required  to  remove  a  small 
amount  of  viscid  mucus.  The  sputum  may  be  clear,  yellowish, 
or  brownish  in  appearance,  and  it  is  usually  expectorated  in 
small  pellets  or  lumps.  The  expectorated  matter  is  sometimes 
stained  with  dark  spots  of  pigment,  or  it  may  be  streaked  with 
blood.  It  is  never  abundant  unless  bronchitis  co-exists. 

Usually  the  tongue  is  red  and  thick,  with  prominent  papillae, 
and  covered  with  a  yellow  pasty  or  creamy  fur. 

The  mucous  membrane  of  the  throat  and  palate  is  relaxed 
and  puffy,  and  usually  redder  than  normal. 

The  appetite  is  not  generally  affected. 

The  bowels  are  usually  constipated,  and  occasionally  the 
individual  suffers  from  dyspepsia. 


CHRONIC  LARYNGITIS. 

«J  O/ 

Exceptional.— In  a  few  rare  instances,  termed  fetid  chronic  laryngitis,  the  excre- 
tions are  very  viscid,  exceedingly  offensive,  and  are  only  coughed  up  at  long  intervals 
of  from  one  to  three  or  four  days.  They  consist  of  yellowish,  grayish,  or  brownish 
crusts,  due  to  desiccation  or  to  decomposition. 

SIGNS. 

On  inspection,  the  entire  mucous  membrane  of  the  larynx  is 
generally  congested  and  puffy,  but  in  some  instances  this  con- 
dition is  limited  to  circumscribed  portions,  the  redness  gradu- 
ally fading  off  into  healthy  tissue.  Tumefaction  is  not  so  great 
as  in  acute  laryngitis. 

When  the  inflammation  is  limited  to  a  part  of  the  larynx,  it 
occurs  as  regards  frequency  of  situation  in  the  following  order : 
first,  on  the  supra-arytenoid  cartilages ;  second,  on  the  ventric- 
ular bands  ;  third,  on  the  epiglottis;  fourth,  on  the  vocal  cords ; 
lastly,  on  the  ary-epiglottic  folds. 

When  the  epiglottis  is  affected  it  is  frequently  flaccid,  so  that 
its  edges  are  rolled  together  during  acts  of  retching.  When 
the  vocal  cords  are  inflamed  they  are  of  a  pink  or  reddish  hue, 
and  their  edges  are  occasionally  uneven  or  granular.  The 
minute  blood-vessels  on  the  epiglottis  are  frequently  turgid, 
and  may  be  seen  crossing  from  the  base  towards  its  free  edge. 
Often  blood-vessels  may  be  seen  running  longitudinally  along 
the  vocal  cords,  especially  at  their  attached  borders.  The 
congestion  of  the  cords  may  be  uniform,  or  limited  to  their 
attached  borders  or  posterior  extremities.  One  cord  may  be 
congested  and  the  other  of  a  normal  white  appearance. 

Streaks  or  pellets  of  mucus  are  frequently  seen  adhering  to 
the  walls  of  the  larynx,  especially  upon  the  inter-arytenoid 
commissure,  or  upon  the  ventricular  bands  or  vocal  cords. 
Mucus  is  sometimes  observed  temporarily  sticking  the  vocal 
cords  together;  or  stretching  in  strands  from  one  to  the  other 
in  inspiration. 

In  cases  of  long  standing,  the  larynx  sometimes  has  the 
appearance  of. being  dilated,  and  the  surface  is  covered  with 
secretion,  but  in  other  instances  the  mucous  membrane  is  dry 
and  glistening.  Usually  the  vocal  cords  are  not  perfectly 
approximated  during  phonation,  owing  to  congestion,  or  thick- 
ening of  the  connective  tissue,  or  to  atrophy  of  the  muscles. 
Sometimes  tumefaction  and  hypertrophy  of  the  muscular  por- 
tions of  the  cords,  especially  on  their  under  surface,  causes  the 


22 


338  THE   THROAT   AND   NASAL   CAVITIES. 

inferior  portions  of  the  cords  to  project  into  the  larynx  just 
beneath  the  glottis  in  irregular  longitudinal  welts  or  folds,  so 
as  nearly  to  occlude  the  calibre  of  the  larynx,  and  cause  such 
dvspnoea  as  to  render  tracheotomy  necessary.  The  mobility 
of  the  cords  is  frequently  impaired,  either  by  the  mechanical 
effects  of  the  inflammatory  exudation  or  by  paresis  of  the 
muscles. 

The  glands  at  the  base  of  the  tongue  are  sometimes  greatly 
hypertrophied. 

When  ulceration  has  taken  place,  the  destruction  of  tissue 
seldom  involves  more  than  the  epithelial  layer,  though  necrosis 
of  the  whole  depth  of  the  mucous  membrane  or  even  of  the 
cartilages  is  said  to  occur  in  rare  instances. 

In  simple  chronic  laryngitis  one  or  more  superficial  ulcers 
are  frequently  found  at  the  posterior  extremity  of  the  vocal 
cords,  and  upon  the  inner  surface  of  the  arytenoid  cartilage,  or 
of  the  inter-arytenoid  commissure.  They  are  also  found  occa- 
sionally on  the  ary-epiglottic  fold.  When  indolent  these  are 
usually  covered  with  a  grayish  or  ashy  colored  secretion,  of 
pulpy  or  membranous  appearance ;  the  separation  of  which,  by 
means  of  a  bit  of  sponge  or  pledget  of  lint,  causes  slight  bleed- 
ing. Healthy  ulcerations  are  covered  with  laudable  pus,  and 
the  processes  of  repair  are  indicated  about  their  edges. 

The  deeper  ulcerations  are  nearly  always  associated  with 
phthisis  or  syphilis.  Accumulations  of  mucus  are  usually  found 
in  the  glosso-epiglottic  or  pyramidal  sinuses,  and  ulcers  may 
occur  in  the  same  localities. 

DIFFERENTIAL  DIAGNOSIS. 

Simple  chronic  laryngitis  is  liable  to  be  mistaken  for  paralysis 
of  the  vocal  cords,  oedema  of  the  larynx,  and  tuberculous  or 
syphilitic  laryngitis.  An  accurate  diagnosis  can  only  be  made 
upon  careful  laryngoscopic  examination,  though  the  symptoms 
and  history  are  also  of  great  importance. 

Paralysis. — In  the  dysphonia  due  to  paralysis  the  voice  is 
clearest  in  the  morning  or  after  rest,  but  it  gradually  becomes 
hoarse  upon  use.  This  is  rarely  the  case  in  chronic  laryngitis, 
in  which  the  voice  is  usually  hoarse  in  the  morning,  but  im-, 
proves  with  use.  Paralysis  of  the  vocal  cords  causes  loss  of 


CHRONIC   LARYNGITIS. 

motion,  which  may  be  easily  detected  by  the  laryngoscope. 
This  at  once  determines  the  nature  of  the  disease. 

CEdcuia  of  the  larynx  causes  pyriform  swelling  of  the  supra- 
arytenoid  cartilages  and  ary-epiglottic  folds,  or  of  the  epiglot- 
tis. This  does  not  occur  in  chronic  laryngitis.  The  light 
color  and  semi-transparent  appearance  of  this  swelling  differs 
materially  from  the  appearance  of  the  chronic  induration  and 
thickening  due  to  phthisis  or  syphilis. 

Tuberculous  Laryngitis. — In  phthisis  pyriform  thickening  of 
the  arytenoid  or  supra-arytenoid  cartilages  soon  occurs  upon 
one  side  or  upon  both  sides,  and  this  is  considered  a  character- 
istic sign.  The  mucous  membrane  is  apt  to  be  anaemic,  but  it 
may  be  nearly  natural  in  color  or  slightly  congested.  The 
lesions  in  the  larynx  are  usually  found  upon  the  same  side  as 
the  physical  signs  in  the  lung. 

Ulcers  are  much  more  frequent  in  tuberculous  than  in  simple 
chronic  laryngitis,  and  in  the  former  they  are  not  so  likely  to 
heal  as  in  the  latter.  The  diagnosis  rests  on  the  history,  the 
symptoms  of  constitutional  disease,  and  the  pyriform  swelling 
of  the  supra-arytenoid  cartilages. 

The  discovery  of  tubercles  in  the  laryngeal  mucous  membrane  would  seem  accord- 
ing to  some  authors  to  be  a  valuable  sign,  but  expert  laryngologists  differ  regarding  the 
visibility  of  these  neoplasms  in  this  situation. 

Syphilitic  Laryngitis  is  distinguished  from  simple  chronic 
laryngitis  with  ulceration  by  the  history,  by  the  presence  of 
cicatrices  in  the  fauces  or  upper  portion  of  the  larynx,  and  by 
the  dirty  grayish  surface  and  undermined  edges  of  the  ulcers. 
The  ulcerations  of  simple  chronic  laryngitis  are  usually  super- 
ficial, and  they  do  not  cause  the  extensive  destruction  of  tis- 
sue, or  leave  the  prominent  scars  which  result  from  specific 
disease. 

TREATMENT. 

We  should  make  use  of  stimulant  or  astringent  applications 
of  chloride  of  .zinc,  sulphate  of  zinc,  or  persulphate  of  iron 
(Form.  94-97).  These  should  be  accurately  applied  with  a 
laryngeal  brush  to  the  affected  parts.  As  a  rule  these  applica- 
tions should  be  made  daily  for  the  first  week,  every  second  day 
during  the  second  week,  and  subsequently  every  third  day.* 

*  Mackenzie's  Diseases  of  the  Throat  and  Nose. 


340  THE   THROAT  AND   NASAL   CAVITIES. 

But  all  cases  cannot  be  treated  alike.  It  is  best  to  begin  with 
mild  applications,  the  strength  of  which  should  be  gradually 
increased  until  the  susceptibility  of  the  part  is  ascertained. 
When  we  have  thus  ascertained  what  the  individual  will  bear, 
the  applications  should  be  continued  daily  until  considerable 
inflammatory  reaction  is  set  up,  and  then  they  should  be  made 
less  frequently,  time  being  allowed  for  the  effects  of  each  appli- 
cation to  subside  fully  before  another  is  made.  In  the  mean 


FIG.  83. — Rappaner's  brush  holder,  one  third  size.  The  point  is  screwed  into  an 
ordinary  camel's-hair  brush,  and  the  stem  may  be  bent  at  any  desired  angle. 

time  weak  solutions  of  the  mineral  astringents  should  be  used 
by  the  patient,  either  with  the  hand-ball,  or  the  steam  ato- 
mizer (Form.  61-65),  or>  m  place  of  these,  stimulating  vapors 
of  the  oil  of  white  pine,  oil  of  cloves,  iodine,  or  carbolic  acid 
can  be  used  with  benefit  (Form.  43,  54,  55,  and  49).  When 
secretion  is  excessive,  turpentine  or  tannic  acid  is  most  useful ; 
but  when  scanty,  carbolic  acid  or  chloride  of  ammonium  is 
preferable.  Stimulating  troches  are  serviceable  in  many  cases 
(Form.  28-31).  When  ulcers  occur,  iodoform  in  solution  or  in 
powder  is  useful  (Form.  1 1 1). 

Excessive  cough  should  be  relieved  by  troches  containing 
small  doses  of  morphia,  by  cough  mixtures,  or  by  sedative  inha- 
lations. Paroxysmal  coughing  is  most  promptly  checked  by  a 
few  inhalations  of  chloroform.  For  this  purpose  half  a  drachm 
of  chloroform  should  be  turned  on  a  bit  of  sponge  placed  at 
the  bottom  of  a  wide-mouthed  bottle — such  as  a  morphia 
bottle.  The  bottle  should  be  closely  corked  and  kept  on  hand 
for  the  time  of  need.  When  a  paroxysm  comes  on,  the  patient 
removes  the  cork  and  takes  a  few  inhalations  from  the  bottle. 
There  is  no  danger  in  allowing  patients  to  use  chloroform  in 
this  manner. 

If  the  general  health  suffers,  as  it  often  does,  tonics  and 
alteratives  will  be  useful.  Change  of  climate  cures  many 
cases.  ' 


CROUP. 


PHLEBECTASIS    LARYNGEA. 

This  term  is  used  to  designate  a  varicose  condition  of  the 
laryngeal  veins.  The  cause  of  the  affection  is  unknown. 

SYMPTOMS  AND  SIGNS. 

The  condition  is  usually  manifested  by  slight  hoarseness,  a 
sensation  of  something  wrong  in  the  larynx,  and  occasional 
cough.  Enlarged,  dark-colored  blood-vessels  may  be  seen  on 
the  epiglottis,  arytenoid  cartilages,  and  ventricular  bands. 

TREATMENT. 

Topical  applications  of  strong  astringents  may  give  some 
relief,  but  the  most  effectual  treatment  is  the  destruction  of 
the  veins  by  the  galvano-cautery.* 

TRACHOMA  OF  THE  VOCAL  CORDS.* 

Synonym. — Chorditis  tuberosa.  This  apparently  arises  from 
a  partial  dermoid  metamorphosis  of  the  mucous  membrane. 
It  is  sometimes  found  after  persistent  chronic  laryngitis ;  and 
is  most  frequently  noticed  in  singers. 

This  condition  is  characterized  by  roughness  of  the  surface 
of  the  cords  with  more  orMess  alteration  of  the  voice. 

TREATMENT. 

The  treatment  is  tedious,  but  a  cure  may  generally  be 
effected  by  the  prolonged  use  of  mineral  astringents  or  mild 
caustics.  Perchloride  of  iron  or  nitrate  of  silver  in  strong 
solutions  are  particularly  recommended. 

CROUP. 

Synonyms.— Pseudo-membranous  croup  ;  Exudative  laryngo- 
tracheitis;  Laryngo-tracheal  diphtheria  (Mackenzie);  Hives 
(Rush) ;  Angina  trachealis. 

This  disease  consists  of  an  inflammation  of  the  mucous  mem- 
brane and  the  muciparous  glands  of  the  upper  air  passages, 

*  Mackenzie's  Diseases  of  the  Throat  and  Nose. 


342  THE   THROAT   AND   NASAL   CAVITIES. 

especially  of  the  larynx,  with  an  exudation,  which,  becoming 
organized,  forms  a  false  membrane.  It  is  attended  in  some 
cases  by  spasm  of  the  glottis,  or  with  paralysis  of  the  abductors 
of  the  vocal  cords. 

The  disease  is  most  frequently  met  with  in  children  between 
the  ages  of  two  and  seven  years,  but  it  may  occur  at  any  age. 

SYMPTOMS. 

The  well-marked  symptoms  of  the  affection  are  usually  pre- 
ceded, for  from  two  to  five  days,  by  the  symptoms  of  slight 
catarrh,  coryza,  or  bronchitis.  At  length  marked  hoarseness  is 
observed  in  the  evening,  and  during  the  succeeding  night 
the  child  is  attacked  by  a  severe  paroxysm  of  suffocation,  due 
partially  to  the  swelling  of  the  mucous  membrane  and  exuda- 
tion on  its  surface,  and  partially  to  spasm  of  the  glottis. 
Subsequently  the  voice  continues  hoarse,  the  cough  ringing  and 
metallic,  and  respiration  becomes  more  and  more  obstructed. ' 
These  symptoms  continue  throughout  the  interval  between 
the  paroxysms ;  which  are  apt  to  recur  from  time  to  time  with 
increasing  frequency  and  severity,  for  one  or  two  days. 
Finally,  owing  to  increased  obstruction  to  inspiration,  the  face, 
losing  its  flush,  becomes  pallid  and  of  an  ashy  hue ;  the  lips 
become  livid ;  sinking-in  of  the  chest  is  seen  at  its  lower  por- 
tion and  above  the  clavicles  during  inspiration,  and  at  last  a 
sudden  paroxysm  or  gradual  closure  ?)f  the  glottis  by  tfie  false 
membrane  causes  death. 

SIGNS. 

Inspection  with  the  aid  of  the  laryngoscope  reveals  the  pres- 
ence of  false  membrane  in  the  larynx. 

DIFFERENTIAL   DIAGNOSIS. 

Croup  is  liable  to  be  mistaken  for  diphtheria,  acute  laryn- 
gitis, or  for  laryngismus  stridulus.  Diphtheria  having  been 
excluded  by  the  history  and  symptoms  and  the  absence  of  any 
considerable  amount  of  exudation  in  the  fauces,  the  differential 
diagnosis  is  determined  at  once  by  the  detection  of  false  mem- 
brane in  the  larynx.  Expectoration  of  patches  or  lumps  of 
false  membrane,  or  detection  of  this  membrane  in  the  larynx 
enables  us  to  distinguish  croup  from  acute  laryngitis.  The 


CROUP.  ,,- 

343 

following  table  indicates  the  principal  points  in  the  differential 
diagnosis  between  croup  and  diphtheria. 

CROUP.  DIPHTHERIA. 

Accession  gradual ;  slight  fever;  spas-  Accession  more  sudden;  high  fever; 

modic  element  prominent.  usually  no  spasmodic  element. 

Little  or  no  exudation  in  the  fauces.  Abundant  exudation  in  the  fauces. 

Exudation  in  the  larynx  is  always  pres-  Exudation  in  the  larynx  seldom  present, 

ent,  and  it  occurs  comparatively  early  in  and  usually  it  does  not  occur  until  late  in 

the  attack.  .  the  attack. 

Laryngitis. — The  differential  diagnosis  between  croup  and 
laryngitis  in  young  children  was  pointed  out  in  the  last  lecture. 

Laryngismus  stridulus.  —  Membranous  croup  differs  from 
laryngismus  stridulus  in  its  more  gradual  accession,  and  in 
the  persistence  of  more  or  less  dyspnoea  and  aphonia  between 
the  paroxysmal  attacks.  The  latter  disease  comes  on  suddenly, 
often  without  a  moment's  warning,  and  no  dyspnoea  remains 
after  the  paroxysm  has  subsided. 

TREATMENT. 

The  patient  should  be  kept  in  a  moist  atmosphere,  at  a 
temperature  of  80°  or  85°  F. 

Locally. —  Early,  before  false  membrane  has  formed,  the 
child  should  constantly  suck  bits  of  ice ;  and  ice-bags  should 
be  applied  constantly  to  the  neck.  At  the  same  time,  cold 
spray  inhalations  of  lactic  acid,  gr.  xx.  to  §  i.,  should  be  em- 
ployed. As  soon  as  membrane  is  believed  to  have  formed,  a 
non-depressing  emetic,  as  alum,  gr.  xxx.  to  lx.,  should  be  given.* 
This  will  remove  a  portion  of  the  membrane  and  give  consid- 
erable relief,  but  the  membrane  is  likely  to  be  quickly  repro- 
duced. In  this  stage,  inhalation  of  the  vapor  of  lime-water  pro- 
pelled by  a  steam  atomizer  has  sometimes  proven  efficient.  The 
spray  should  be  kept  up  constantly  near  the  bed,  and  every 
hour  the  patient  should  inhale  directly  from' it  for  five  or  ten 
minutes.  If  this  fails,  inhalations  of  bromine  (Form.  70)  with 
the  steam  atomizer  should  be  tried,  or  the  two  may  be  used 
alternately.  Insufflation  of  sulphur  has  been  lately  recom- 
mended. 

Internally.—^  the  same  time  liquor  potassae  in  full 
largely  diluted  is  thought  by  some  to  be  very  useful. 

*  Mackenzie's  Diseases  of  the  Throat  and  Nose. 


344 


THE   THROAT   AND   NASAL   CAVITIES. 


ganate  of  potassium  is  beneficial  in  some  cases.  Quinine  and 
strychnia  in  moderate  doses  are  also  indicated.  As  soon  as 
dyspnoea  becomes  urgent,  tracheotomy  must  be  performed. 

Half  a  century  ago,  large  doses  of  calomel  frequently 
repeated  were  highly  recommended,  and  there  is  reason  to 
believe  that  the  remedy  thus  given  has  been  curative  in  many 
cases.  In  the  memoirs  of  the  Rev.  Sidney  Smith  it  is  stated 
that  when  his  little  daughter,  six  months  of  age,  had  a  severe 
attack  of  croup,  he  sent  for  Dr.  Hamilton,  then  one  of  the 
most  prominent  physicians  in  Edinburgh.  Dr.  H.  could  not 
come,  but  sent  back  word,  "  Persevere  in  giving  two  grains 
of  calomel  every  hour ;  I  have  never  known  it  to  fail."  My 
own  experience  with  this  remedy  in  large  and  repeated  doses 
is  limited,  but  so  far  as  it  goes  it  is  favorable.  In  two  cases 
where  the  remedy  was  thus  given  for  twenty  hours,  the  dysp- 
noea disappeared  apparently  as  the  result  of  treatment.  I  can- 
not recommend  a  treatment  of  which  I  know  so  little,  but  it 
seems  to  me  worthy  of  trial  when  ordinary  means  do  not  suc- 
ceed.* 

PHLEGMONOUS   LARYNGITIS. 

Synonyms. — Submucous  laryngitis;  Diffused  abscess  of  the 
larynx  ;  Laryngitis  phlegmonosa  ;  Laryngitis  submucosa  puru- 
lenta;  Laryngitis  sero-purulenta. 

This  is  a  rare  affection,  in  which  inflammation  attacks  the 
submucous  tissues,  causing  suppuration  and  necrosis,  with  the 
formation  of  diffused  or  circumscribed  abscesses  which  are 
generally  located  in  the  upper  portion  of  the  larynx,  at  the  base 
of  the  epiglottis,  or  in  the  aryteno-epiglottidean  folds.  The 
affection  sometimes  involves  the  ventricular  bands,  and  rarely 
tRe  vocal  cords. 

SYMPTOMS. 

The  symptoms  of  the  disease  are  pain,  dysphagia,  hoarseness, 
cough,  expectoration  of  mucus  and  subsequently  of  pus,  dysp- 
noea, and  later  in  the  attack,  delirium. 

*  Some  weeks  after  this  was  sent  to  press,  my  friend,  Dr.  David  Dodge,  of  this  city, 
to  whom  I  had  suggested  this  treatment,  informed  me  that  he  had  found  it  beneficial 
n  several  cases. 


ERYSIPELATOUS   LARYNGITIS.  ,.c 

345 

SIGNS. 

When  a  laryngoscopic  examination  can  be  made,  hypersemia 
and  local  tumefaction  of  the  parts  indicated  will  be  observed, 
and  later  fluctuation  in  the  submucous  areolar  tissue  of  the 
neck  and  chin  will  sometimes  aid  us  in  the  diagnosis. 

TREATMENT. 

Early  the  best  remedies  are  leeches  and  warm  applications 
to  the  neck,  with  steam  inhalations,  or,  instead  of  the  latter,  con- 
stant sucking  of  bits  of  ice.  As  soon  as  there  is  oedema  or  a 
collection  of  pus,  scarification  is  indicated. 

Internally. — Quinine  and  sulphate  of  strychnia  in  medium 
doses  and  chlorate  of  potassium  in  full  doses  are  indicated,  to- 
gether with  nourishing  diet  and  the  free  use  of  stimulants. 
Remedies  and  food  should  be  given  by  enema  if  the  patient 
cannot  swallow.  Urgent  dyspnoea  demands  tracheotomy. 


ERYSIPELATOUS   LARYNGITIS. 

This  is  an  erysipelatous  inflammation  of  the  larynx,  usually 
associated  with  erysipelas  of  the  tongue  and  palate.  It  some- 
times results  from  metastasis  of  cutaneous  erysipelas,  or  from 
its  extension  along  the  mucous  membrane  of  the  nose,  mouth, 
or  ear.  The  inflammation  soon  terminates  in  extensive  suppu- 
ration and  sloughing  in  the  intra-laryngeal  or  peri-laryngeal 
tissues. 

SYMPTOMS. 

The  symptoms  are  fever,  local  pain  and  swelling,  with  diffi- 
culty in  speaking,  dyspnoea,  and  great  prostration.  In  severe 
cases,  these  symptoms  are  usually  succeeded  by  vomiting  and 
finally  by  delirium. 

SIGNS. 

Early  in  the  disease  the  laryngoscopic  appearances  are  simply 
those  of  laryngitis;  subsequently  sloughs  or  extensive  ulcers 
will  be  observed. 

DIAGNOSIS. 

The  diagnosis  must  be  based  upon  the  symptoms  and  the 
evidence  of  inflammation  of  the  same  type,  affecting  the  skin 
or  the  mucous  membrane  of  the  mouth. 


346  THE   THROAT   AND   NASAL  CAVITIES. 

TREATMENT. 

The  general  treatment  should  be  the  same  as  for  erysipelas 
in  other  localities.  Quinine  and  tincture  of  iron  are  the  most 
useful  medicines.  Nourishing  diet  is  essential,  and  stimulants 
are  indicated  early. 

Locally. — In  hopes  of  aborting  the  attack,  ice  may  be  sucked 
constantly  for  the  first  few  hours.  Gibb  reports  a  case  in  which 
applications  of  a  strong  solution  of  nitrate  of  silver  (gr.  Ixxx. 
ad  |  i.)  every  six  hours  cut  short  the  disease.  Steam  inhala- 
tions and  anodynes  will  be  useful  in  relieving  pain. 

Tracheotomy  will  naturally  suggest  itself,  but  it  is  of  doubt- 
ful propriety. 


LECTURE    XXX. 
DISEASES   OF   THE   LARYNX— Continued. 

ABSCESS   OF   THE   LARYNX. 

This  consists  of  a  circumscribed  collection  of  pus,  due  to 
inflammation  of  the  soft  tissues.  It  is  very  rarely  a  primary 
affection.  It  occurs  not  infrequently  as  the  result  of  inflamma- 
tion of  the  cartilages  or  perichondrium  following  typhoid 
fever  or  pyasmia,  or  dependent  upon  tuberculosis,  syphilis,  or 
local  injuries. 

Abscesses,  occurring  as  the  result  of  typhoid  fever,  are  gener- 
ally found  during  the  second  or  third  week  of  the  fever.  The 
smaller  of  these  appear  just  beneath  the  mucous  membrane, 
and  the  larger  ones  beneath  the  perichondrium. 

SYMPTOMS. 

The  symptoms  of  abscess  of  the  larynx  are:  pain  which  is 
aggravated  by  pressure,  cough,  difficulty  in  swallowing,  and 
dyspnoea. 


FIG.  84.— Infra-glottic  abscess  of  lar-  FIG.  85.— The  same  twelve  hours  after 

ynx,  due  to  syphilis.     Great  dyspnoea.  spontaneous  opening  of  abscess. 

SIGNS. 

Upon  laryrigoscopic  examination,  the  abscess  appears  as  a 
glistening  swelling,  red  at  its  base,  and  either  red  or  yellowish 
at  its  apex.  It  is  usually  located  on  the  inner  surface  of  the 
larynx,  either  at  the  base  of  the  epiglottis,  upon  the  arytenoid 
or  supra-arytenoid  cartilages,  or  in  the  aryteno-epiglottidean 
folds. 


348  THE   THROAT   AND   NASAL  CAVITIES. 

DIAGNOSIS. 

In  children  the  disease  is  liable  to  be  mistaken  for  croup  or 
retro-pharyngeal  abscess,  and  the  diagnosis  is  sometimes 
attended  with  great  difficulty.  But  in  adults  the  laryngoscopic 
appearances  are  characteristic  if  the  abscess  points  ;  otherwise 
it  is  not  always  possible  to  distinguish  it  from  simple  inflam- 
matory swelling.  This  condition  can  usually  be  distinguished 
from  oedema  by  the  greater  transparency  of  the  swelling  in  the 
latter. 

TREATMENT. 

When  the  abscess  can  be  reached,  the  pus  should  be  evacu- 
ated by  means  of  the  laryngeal  lancet.  When  this  cannot  be 
accomplished,  the  patient  must  be  carefully  watched,  and  if 
dyspnoea  becomes  threatening,  tracheotomy  must  be  performed. 
Subsequently,  with  the  trachea  completely  stopped  by  a  large 
canula,  renewed  efforts  should  be  made  to  open  the  abscess. 

(EDEMA   OF   THE   LARYNX. 

Synonyms. — CEdematous  laryngitis ;  Submucous  laryngitis  ; 
Supra-  or  infra-glottic  dropsy  ;  Angina  laryngea  infiltrata ;  (in- 
correctly) (Edema  glottidis. 

This  consists  of  a  sero-sanguinolent  or  sero-purulent  infiltra- 
tion into  the  areolar  tissue  beneath  the  mucous  membrane, 
which,  owing  to  the  formation  of  the  parts,  at  once  diminishes 
the  size  of  the  air  tube,  causing  dyspnoea,  and  unless  the  proc- 
ess is  checked  or  promptly  relieved,  speedily  induces  suffoca 
tion.  A  spasmodic  element  frequently  co-exists  with  the 
mechanical  interference  to  respiration,  ,and  thus  adds  greatly 
to  the  gravity  of  the  case. 

SYMPTOMS. 

Acute  oedema  usually  comes  on  suddenly,  and  the  symptoms 
increase  in  severity,  with  great  rapidity,  giving  rise  to  frequent 
suffocative  attacks,  with  intervals  of  less  impeded  respiration. 
These  intervals  grow  shorter  and  shorter  until  relief  is  obtained 
or  death  occurs. 

When  oedema  follows  chronic  diseases,  the  progress  of  the 
case  is  more  gradual.  At  first,  symptoms  due  to  slight  ob- 
struction present  themselves.  These  gradually  increase  in 


CEDEMA   OF   THE   LARYNX.  340 

severity,  until  finally  a  suffocative  paroxysm  occurs,  which 
usually  subsides  after  a  short  time,  to  recur  after  a  few  hours, 
and  again  and  again  at  shorter  intervals,  as  in  the  acute  affec- 
tion, until  it  proves  fatal.  The  symptoms  referable  to  the 
larynx  are  slight  local  tenderness,  with  a  sense  of  dryness,  heat, 
and  constriction  in  the  throat,  hoarseness,  aphonia,  dyspnoea 
with  labored  and  sometimes  stridulous  respiration,  and  more 
or  less  difficulty  in  swallowing.  The  inspiratory  act  is  chiefly 
'Obstructed,  expiration  being  comparatively  free,  and  this  is  an 
important  point  in  the  diagnosis. 

SIGNS. 

Upon  inspection,  the  fauces  are  sometimes  found  to  be 
cedematous,  and  by  the  aid  of  the  laryngoscope  the  epiglottis, 
or  aryteno-epiglottidean  folds,  or  both,  are  found  to  be  greatly 
swollen,  and  occasionally  the  ventricular  bands  or  vocal  cords 


FIG.  86.— (Edema  of  larynx  (Cohen). 

are   also   affected.     The  swollen   parts  are  translucent,  of  a 
pinkish  or  yellowish  color,  and  closely  resemble,  in  their  gei 
eral  appearance,  an  cedematous  eyelid  or  prepuce. 
glottis  has  the  appearance  of  a  roll-like  body  or  ndge,  and 
aryteno-epiglottidean  folds  are  globular  or  irregular  i 
and  usually  project  from  both  sides;  though  occas:onally  c 
one  side  is'involved,  and  at  other  times  the  swelling  i 
on  one  side  than  on  the  other. 

Exceptionally  the  «iema  is  limited  to  the  parts  below  the  vocal  cords. 


350  THE   THROAT   AND    NASAL  CAVITIES. 

The  swelling  may  narrow  the  upper  orifice  of  the  larynx  to 
a  mere  slit. 

DIAGNOSIS. 

The  diagnosis  can  sometimes  be  made  by  passing  the  finger 
over  the  base  of  the  tongue,  where  the  cedematous  epiglottis 
or  the  aryteno-epiglottidean  fold  may  be  felt.  This  method, 
however,  must  be  practiced  with  great  care  and  very  gently, 
as  it  might  induce  a  dangerous  suffocative  paroxysm.  Lifting 
the  larynx  by  external  manipulation  does  not  relieve  the  dysp- 
noea, as  it  would  in  retro-pharyngeal  abscess.  This  is  there- 
fore a  valuable  sign  when  the  disease  occurs  in  young  children. 

A  laryngoscopic  examination  will  at  once  settle  all  questions 
as  to  diagnosis,  for  there  are  no  other  affections  presenting 
similar  appearances. 

Chronic  infra-glottic  oedema,  or  thickening  of  the  inferior 
surface  of  the  vocal  cords,  causes  a  pinkish-white  fold  immedk 
ately  below  the  vocal  cord  on  one  or  both  sides,  and  some- 
times around  the  entire  circumference  of  the  glottis. 


FIG.  87. — Chronic  swelling  of  the  un-  FIG.  88. — Slight  subglottic  oedema  in 

der  surface  of  the  vocal  cords  (Ziemssen).         a  phthisical  patient. 

TREATMENT. 

I  have  obtained  prompt  and  complete  relief  by  the  adminis- 
tration of  a  drachm  dose  of  the  fluid  extract  of  jaborandi.  This 
remedy  is  very  uncertain  in  its  action,  or  rather  in  its  quality. 
A  good  preparation  given  in  this  dose  will  cause  profuse  sali- 
vation or  diaphoresis,  or  both,  in  about  twenty  minutes,  but 
unfortunately  most  of  this  medicine  is  worthless.  By  trying 
different  preparations,  first  from  one  drug  store  and  then  from 
another,  we  can  usually  find  an  efficient  article,  and  when 
found  we  should  keep  a  few  ounces  of  it  for  cases  of  emergency. 
The  medicine  often  causes  vomiting  after  two  or  three  hours, 
but  this  result  is  also  favorable  in  oedema  of  the  larynx.  If  we 


TRACHEITIS.  35  j 

fail  with  this  remedy,  scarification  of  the  larynx  is  the  best 
treatment.  If  this  does  not  afford  relief,  tracheotomy  must  be 
performed. 

Chronic  oedema  of  the  larynx  should  be  treated  by  scarifica- 
tion, followed  by  the  stronger  stimulating  or  astringent  pig- 
ments, as  chloride  of  zinc,  or  nitrate  of  silver.  When  the 
oedema  is  located  below  the  vocal  cords,  very  little  can  be 
accomplished  by  topical  applications.  Schroetter's  method 
of  dilating  the  larynx*  by  means  of  hard-rubber  tubes  has  been 
very  successfully  employed  in  cases  of  this  kind.  If  dyspnoea 
becomes  marked,  tracheotomy  must  be  performed. 


FIG.  89. — Mackenzie's  laryngeal  lancet — $  of  ordinary  size. 

TRACHEITIS. 

This  is  an  inflammation  of  the  trachea,  which  is  frequently 
associated  with  subacute  laryngitis,  or  with  bronchitis  ;  but 
occasionally  it  occurs  independently. 

SYMPTOMS. 

The  principal  symptoms  are  pain  in  the  neck  and  beneath 
the  upper  portion  of  the  sternum,  with  a  slight  hacking,  but 
sometimes  a  paroxysmal  and  peculiar  brazen,  cough. 

SIGNS. 

The  mucous  membrane  of  the  trachea  is  of  a  bright  red  or 
purplish  hue,  and  in  chronic  cases  it  is  often  partially  covered 
with  masses  of  tenacious  mucus.  Care  must  be  taken,  when 
inspecting  the  trachea,  not  to  be  led  into  error  by  the 

*  See  stenosis  of  larynx,  p.  3&3- 


CCLLEGIE 


352  THE   THROAT   AND   NASAL  CAVITIES. 

nation.  We  must  always  remember  that  a  poor  illumination 
gives  it  a  darker-red  appearance  than  it  has  when  examined 
with  a  bright  light.  Occasionally  small  ulcers  may  be  de- 
tected, but  these  are  so  closely  simulated  in  appearance  by 
lumps  of  mucus  that  we  must  be  guarded  in  our  opinion. 

DIAGNOSIS. 

The  disease  may  readily  be  distinguished  from  laryngitis  or 
bronchitis  by  the  laryngoscopic  appearances  and  by  absence 
of  the  auscultatory  signs  of  the  latter  .affection. 

TREATMENT. 

The  treatment  is  essentially  the  same  as  for  bronchitis,  but  in 
tracheitis  more  benefit  is  to  be  expected  from  sedative  and 
stimulating  inhalations,  than  when  the  inflammation  is  located 
in  the  bronchial  tubes. 

CHONDRITIS    AND    PERICHONDRITIS   OF    THE    LARYN- 
GEAL   CARTILAGES. 

This  is  an  inflammation  of  the  cartilages  or  perichondrium 
of  the  larynx,  with  more  or  less  caries  of  the  cartilages.  In 
mild  cases  the  remaining  portions  of  the  cartilage  may  become 
slightly  enlarged.  In  severe  cases  the  whole  cartilage  may  be 
destroyed  and  thrown  off,  or  the  resulting  abscess  may  cause 
suffocation. 

The  disease  sometimes  occurs  as  a  primary  affection,  but  it 
is  usually  associated  with  tuberculosis  or  syphilis,  or  it  follows 
typhoid  fever. 

SYMPTOMS. 

The  inflammation  of  these  tissues  gives  rise  to  more  or  less 
pain,  dysphagia,  hoarseness  and  dyspnoea,  and  usually  to  the 
formation  of  an  abscess. 

SIGNS. 

When  of  primary  origin  the  inflammation  usually  begins  in 
the  perichondrium  or  in  the  cartilage ;  but  when  secondary 
these  tissues  are  generally  affected  by  the  extension  of  an  ulcer- 
ative  process  from  the  mucous  membrane.  Larvngoscopy  re- 
veals the  signs  of  inflammation,  viz.,  more  or  less  tumefaction 
and  loss  of  motion,  with  ulcerations  or  abscesses.  If  the  aryte- 


UJGS 


TUBERCULOUS  LARYNGITIS.  353 

noid  cartilages  are  affected,  the  movements  of  the  vocal  cords 
will  be  restricted.  If  an  abscess  forms,  involving  the  cricoid, 
it  will  project  in  a  tumid  fold  just  beneath  the  vocal  cords ;  if 
it  affects  the  arytenoid  cartilages  it  will  be  seen  above  the 
glottis,  or  if  it  springs  from  the  thyroid  it  will  usually  be  seen 
below  the  vocal  cords,  unless  it  should  point  externally. 

DIAGNOSIS. 

Primary  perichondritis  may  be  suspected  when  the  patient 
complains  of  a  dull  aching  or  boring  pain,  and  laryngoscopic 
examination  reveals  enlargement  of  some  of  the  cartilages  with- 
out much  congestion  of  the  parts. 

Secondary  perichondritis  may  escape  notice  on  account  of 
swelling  of  the  parts.  Late  in  the  affection  abscesses  are 
formed,  the  movements  of  the  vocal  cords  become  impaired, 
distortion  of  the  larynx  may  occur  without  the  presence  of 
cicatricial  tissue,  and  often  a  fetid  discharge  takes  place. 

TREATMENT. 

Whether  the  disease  is  of  primary  or  of  secondary  origin,  the 
patient's  general  health  must  receive  our  principal  attention. 
When  an  abscess  forms  it  must  be  opened,  or  tracheotomy  must 
be  performed  to  prevent  suffocation. 

TUBERCULOUS   LARYNGITIS. 

Synonyms. — Laryngeal  phthisis ;  Phthisis  laryngea ;  Laryngo- 
phthisis ;  Helcosis  laryngis  ;  Throat  consumption,  etc. 

This  affection  causes  chronic  thickening  and  ulceration  of 
the  laryngeal  tissues,  attended  with  hoarseness,  aphonia,  dys- 
phagia,  and  dyspnoea ;  with,  persistent  increase  of  temperature 
and  progressive  emaciation.  It  is  generally  preceded  by  pul- 
monary phthisis,  but  it  is  occasionally  primary. 

SYMPTOMS. 

The  history  and   symptoms  of   the  disease  are  sometimes 
simply  those  of  the  pulmonary  affection  with  which  it  co-exists : 
but  in  most  instances  it  occasions  the  laryngeal  symptoms  just 
referred  to,  together  with  pain  in  the  throat,  which  is  aggra 
vated  by  pressure  and  by  phonation  or  by  efforts  at  deglutu 
It  often  causes  stridulous  respiration. 
23 


354 


THE    THROAT  AND   NASAL   CAVITIES. 


There  is  usually  a  tickling-  sensation  in  the  throat,  giving 
rise  to  frequent  and  severe  paroxysms  of  cough. 

If  the  larynx  alone  is  affected,  the  expectoration  is  compara- 
tively scanty,  but  when  the  lungs  are  involved,  or  when  bron- 
chitis exists,  the  sputum  is  abundant. 

Even  in  cases  where  the  larynx  is  the  only  part  affected, 
patients  may  suffer  from  persistent  elevation  of  temperature, 
with  hectic  exacerbations,  night-sweats,  progressive  emaciation, 
and  indeed  all  the  symptoms  of  pulmonary  phthisis. 

SIGNS. 

The  essential  signs  are:  extreme  pallor  of  the  larynx  at  first, 
which  is  soon  followed  by  a  semi-solid  pyriform  swelling  of 
the  inner  extremity  of  one  or  both  ary-epiglottic  folds  (Fig.  90). 
These  are  usually  associated  with  signs  of  pulmonary  disease. 


FIG.  90.  —  Tuberculous  laryngitis, 
showing  pyriform  swelling  of  left  ary- 
epiglottic  fold  and  paresis  of  left  vocal 
cord. 


FIG.  91.  —  Tuberculous  laryngitis, 
showing  pyriform  swelling  of  both  ary- 
epiglottic  folds  and  thickening  of  epiglot- 
tis. 


On  auscultation  over  the  larynx  or  trachea,  rales  may  usually 
be  heard.  Upon  inspection  of  the  larynx  we  usually  observe, 
early  in  the  case,  a  characteristic  anaemia,  which  may  be  followed 
by  circumscribed  hypercemia,  with  exudation  into  the  ary-epi- 
glottic folds,  about  the  supra-arytenoid  cartilages  of  one  or  both 
sides.  When  both  ary-epiglottic  folds  are  affected,  they  resem- 
ble two  large  pyriform  tumors,  the  large  ends  of  which  are 
together.  The  inter-arytenoid  fold  or  commissure  is  usually 
absorbed  into  these  swellings,  which  then  have  a  smooth  uni- 
form surface ;  but  at  first  the  cartilages  cause  projections 
beyond  the  surrounding  tissues.  When  only  one  side  is 
affected,  the  swelling  is  usually  found  upon  the  same  side  that 
the  phthisical  changes  are  taking  place  in  the  chest.  These 
swellings  are  usually  of  a  pale  pinkish  hue ;  but  they  may 
be  much  congested. 


TUBERCULOUS   LARYNGITIS. 


355 


Early  in  the  disease  the  inter-arytenoid  fold  is  usually  red 
and  swollen,  with  irregular  projections  on  its  laryngeal  surface, 
which  gradually  acquire  the  appearance  of  acuminated  or  con- 
dylomatous  submucous  tumors.  The  epiglottis  is  sometimes 
flaccid,  in  other  cases  it  is  thickened  to  two  or  three  times  its 
ordinary  size,  and  hangs  so  low  over  the  larynx  as  to  prevent 
inspection  of  the  parts  below.  In  addition  to  the  thickening 
it  is  frequently  curled  backward,  so  that  its  edges  cannot  be 
seen.  Thickening  of  the  arytenoids  is  common,  and  finally 
irregular  ulceration  occurs  in  various  parts  of  the  larynx.  The 
ulcers  are  most  frequently  found  at  the  point  of  two  opposing 
surfaces,  and  they  are  generally  multiple ;  but  they  may  be 
confined  to  any  portion  of  the  walls  of  the  larynx,  as,  for  ex- 
ample, the  inner  surface  of  the  arytenoid  cartilages,  the  inter- 
arytenoid  fold,  the  ventricular  bands,  the  base  or  edge  of  the 
epiglottis,  or  to  the  vocal  cords.  Thickening  or  ulceration  of 


FIG.  92. — Tuberculous  laryngitis,  showing  thickening  of  the  epiglottis  and  supra- 
arytenoid  cartilages,  with  ulceration  of  the  vocal  cords  and  left  ventricular  band. 

the  posterior  extremity  of  the  ventricular  bands,  owing  to  their 
position,  frequently  escapes  detection  until  the  morbid  process 
has  become  quite  extensive. 

When  the  vocal  cords  are  affected,  ulceration  usually  occurs 
at  the  vocal  process  ;  but  the  free  edge  of  the  cord  may  be  more 
or  less  affected,  so  as  to  give  it  a  notched  appearance.  Occa- 
sionally, vegetations  on  the  cords  become  ulcerated,  adhesive 
inflammation  is  set  up,  and  the  two  may  be  bound  together  by 
a  cicatricial  web,  similar  to  that  more  frequently  found  in 
syphilis. 

The  aspect  of  tuberculous  ulcers  is  not  characteristic,  though 
they  are  usually  deeper  than  those  of  simple  chronic  laryngitis, 
but  not  so  deep  as  those  of  syphilis.  They  have  little  tendency 
to  heal,  and  therefore  cicatrices  will  seldom  be  found  in  this 
disease. 


THE   THROAT   AND   NASAL    CAVITIES. 

Ulcerations  of  the  trachea  often  occur,  but  owing  to  the 
position  they  can  seldom  be  satisfactorily  inspected. 

Lat6  in  the  disease  perichondritis  or  chondritis,  with  greater 
or  less  destruction  of  the  cartilages,  is  likely  to  occur.  This 
feature  in  the  case  is  indicated  by  local  swelling,  and  pain  on 
phonation  or  deglutition,  with  tenderness  upon  local  pressure 
or  external  manipulation  of  the  larynx.  The  position  of  result- 
ing abscesses  would  indicate  the  cartilages  affected.  When 
there  is  doubt  as  to  whether  it  be  the  arytenoid  or  the  cricoid 
cartilages,  the  supra-  or  infra-glottic  position  of  the  abscess 
will  determine. 

DIAGNOSIS. 

This  affection  is  likely  to  be  mistaken  for  syphilitic  laryn- 
gitis, simple  chronic  laryngitis  with  ulceration,  or  for  chronic 
oedema.  The  most  important  points  in  the  formation  of  the 
diagnosis  are  the  extreme  anaemia  and  the  presence  of  several 
small  and  comparatively  superficial  ulcers,  which  are  situated 
on  a  pale  ground  at  the  lower  part  of  the  larynx,  or  which 
may  have  gradually  extended  from  that  position  upward  ;  with 
pyriform  swelling  of  the  ary-epiglottic  folds,  and  a  history  of 
pulmonary  phthisis.  The  distinctive  features  between  tuber- 
culous and  syphilitic  laryngitis  will  be  seen  in  the  following 
table  : 

TUBERCULOUS  LARYNGITIS.  SYPHILITIC  LARYNGITIS. 

History  of  phthisis.     Swelling  of  aryte-  History  of  syphilis.     Swelling  irregular, 

noids  uniform.     Ulcers  usually  multiple,  Ulcers  usually  single,  deep,  and  excavated, 

small,  and  superficial,  with  a  whitish  base,  with  rounded  undermined  edges,  having  a 

surrounded  by  pale  mucous    membrane.  dirty  grayish  base.     The  ulcers  are  sur- 

The  ulceration  beginning   at   the   lower  rounded  by  an  inflamed  areola,  and  they 

portion  of  the  larynx.  usually  begin  in  the  pharynx  and  gradu- 
ally extend  to  the  upper  portion  of  the 
larynx. 

When    the    epiglottis   is   attacked,  its  When    the   epiglottis   is   attacked,    its 

laryngeal  surface  is  most  deeply  involved.  lingual  surface  is  usually  most  deeply  in- 

The  entire  valve  is  seldom  destroyed.  volved.     The  entire  valve  is  frequently 

destroyed. 

Ulceration  of  the  arytenoid  cartilages,  Ulceration  of  the  arytenoid  cartilages, 

ventricular  bands,  or  anterior  commissure  ventricular  bands,  or  anterior  commissure 

of  the  vocal  cords  is  common.     Both  vo-  of  the  vocal  cords  is  rare.     Often  only 

cal  cords  are  generally  ulcerated  if  either  one  vocal  cord  is  involved, 
is  involved. 

Development  of   ulcers  slow.     Ulcers  Development  of  ulcers  acute.     Ulcers 

often  very  painful.  seldom  painful. 


TUBERCULOUS    LARYNGITIS. 

TUBERCULOUS   LARYNGITIS.  SYPHILITIC   LARYNGITIS. 

Ulcers  do   not  ordinarily  heal,  conse-  Ulcers  generally  heal;  cicatrices  may 

quently  no  cicatrices.  usually  be  observed  in  the  pharynx  and 

upper  portions  of  the  larynx. 
Treatment  has  little  effect.  Appropriate   constitutional    and    local 

treatment  causes  speedy  improvement. 

Tuberculosis  and  syphilis  frequently  co-exist  in  the  same 
case,  and  then  a  diagnosis  may  be  impossible. 

Chronic  catarrhal  laryngitis  is  not  likely  to  be  mistaken  for 
this  disease  excepting  when  ulcerations  have  occurred,  and 
then  the  character  of  the  ulcer,  which  is  generally  a  simple 
abrasion,  together  with  hypersemia  instead  of  anaemia  and 
absence  of  a  phthisical  history,  will  ordinarily  render  the  diag- 
nosis easy.  But  it  must  not  be  forgotten  that  non-tuberculous 
ulcers  may  sometimes  supervene  in  phthisical  patients. 

Chronic  (edema  may  ordinarily  be  distinguished  from  tuber- 
culous laryngitis  by  the  greater  transparency  of  the  tissues  in 
the  former ;  however,  oedema  frequently  occurs  with  the  tuber- 
culous affection,  and  causes  swelling  of  the  supra-arytenoid 
cartilages  and  epiglottis. 

TREATMENT. 

The  general  treatment  should  be  the  same  as  for  pulmonary 
phthisis.  It  consists  of  chloride  of  calcium,  alcoholics,  and 
cod-liver  oil  or  maltine,  with  such  other  rsmedies  as  concom- 
itant symptoms  may  suggest. 

Locally.— Soothing  inhalations  of  lupulin,  benzoin,  or  bella- 
donna sometimes  give  great  relief  (Form.  36,  37,  39).  Cough- 
ing may  be  relieved  by  small  doses  of  morphia  given  in  troches 
(Form.  21).  Severe  paroxysms  of  cough  may  be  relieved  by  a 
few  inhalations  of  chloroform  or  ether.  When  the  secretion 
from  the  larynx  is  excessive,  the  insufflation  of  tannin  should 
be  tried  (Form.  107).  If  tannin  proves  too  irritating,  iodoform 
or  iodoform  combined  in  various  proportions  with  tannin  or 
bismuth  may  be  beneficially  employed  (Form,  in  and  112). 
To  soothe  the  cough  and  relieve  the  pain,  morphia  and  bismuth 
are  useful  (Form.  113).  Sedative  troches  are  also  indicated 
(Form.  21-24).  To  promote  healing  of  ulcers,  pigments 
chloride  of  zinc,  perchloride  of  iron,  iodoform,  or  strong  solu- 
tions of  nitrate  of  silver  are  most  beneficial  (Form.  99-i°5)- 


358  THE   THROAT   AND   NASAL   CAVITIES. 

To  prevent  the  pain  in  deglutition  and  enable  the  -patient  to 
eat,  nothing  has  proven  so  useful  in  my  experience  as  the  pig- 
ment of  morphia,  carbolic  acid,  and  tannin  (Form.  91).  The 
local  anaesthesia  produced  by  this  will  continue  several  hours, 
and  will  often  last  for  two  days. 

SYPHILITIC  LARYNGITIS. 

This  is  a  local  manifestation  of  syphilis ;  the  laryngeal  phe- 
nomena of  which  vary  at  different  epochs  of  the  constitutional 
disease.  The  primary  sore  cannot  occur  in  this  locality.  In 
secondary  syphilis,  chronic  hyperaemia  and  superficial  ulcera- 
tions  are  often  met  with,  but  condylomata  form  the  most 
characteristic  condition.  These  are  usually  from  an  eighth  to 
a  quarter  ot  an  inch  in  diameter,  and  round  or  oval  in  form, 
with  a  smooth  surface,  and  of  a  yellowish  color.  They  are 
generally  located  on  the  epiglottis  or  in  the  inter-arytenoid 
commissure. 

SYMPTOMS. 

We  usually  obtain  symptoms  similar  to  those  of  chronic 
laryngitis.  Pain  seldom  occurs,  though  it  is  present  in  a  few 
instances.  The  absence  of  this  symptom  is  a  valuable  point  in 
the  differential  diagnosis.  Dysphonia,  aphonia,  dyspnoea,  and 
dysphagia  are  more  or  less  marked.  Expectoration  is  usually 
slight ;  sometimes  the  sputum  has  a  peculiar  odor,  and  this,  by 
some  authors,  is  considered  characteristic  of  the  disease. 

SIGNS. 

The  fauces  generally  present  evidences  of  the  specific  affec- 
tion, and  upon  inspection  of  the  larynx  general  hyperaemia  is 
observed,  which,  however,  does  not  differ  essentially  from  that 
of  chronic  catarrhal  laryngitis.  Small-sized,  superficial  ulcers 
are  often  found  in  the  fauces  and  upon  the  epiglottis,  which 
usually  occur  between  the  sixth  and  twelfth  month  after  the 
primary  affection. 

Condylomata  are  found  upon  the  epiglottis,  vocal  cords,  or 
inter-arytenoid  fold  in  about  one  fifth  of  all  the  cases. 

DIAGNOSIS. 

The  affection  is  liable  to  be  mistaken  for  tuberculous  laryn- 
gitis or  chronic  catarrhal  laryngitis.  The  diagnosis  must 


SYPHILITIC   LARYNGITIS. 


359 


depend  mainly  upon  the  history,  the  symptoms,  and  the  prog- 
ress  of  the  case.  When  hyperaemia  is  the  only  sign,  it  is  at 
first  impossible  in  some  cases  to  decide  whether  it  is  due  to 
this  disease,  or  to  simple  catarrhal  or  tuberculous  inflamma- 
tion. A  little  time  will  decide  such  cases. 

It  is  claimed  that  narrow  bands  of  hypenemia,  running  along  the  edge  of  the  velum 
of  the  palate  on  both  sides  and  terminating  at  points  equidistant  from  the  base  of  the 
uvula,  together  with  symmetrical  hyperremic  patches  in  the  mouth,  are  almost  unfailing 
signs  of  specific  disease. 


FIG.  93. — Condyloma  on  the  upper  surface  of  the  epiglottis  (Mackenzie). 

The  erosions  of  catarrhal  inflammation  usually  heal  in  a  few 
days,  and  those  of  syphilis  in  a  few  weeks,,  but  those  of  tuber- 
culosis seldom  take  on  the  reparative  process. 

Tertiary  Syphilis. — In  tertiary  syphilis,  besides  the  history 
and  symptoms  of  the  secondary  stage,  we  will  observe  rapid, 
deep  and  extensive  ulceration,  or  gummata  or  cicatricial  steno- 
sis. Often  the  first  sign  of  this  condition  is  obstinate  superfi- 
cial ulceration  of  the  vocal  cords.  Erelong  deeper  tissues  are 
involved,  and  usually  destruction  of  a  part  or  even  of  all  of  the 
epiglottis  occurs,  and  the  process  may  involve  the  deeper  por- 
tion of  the  larynx. 


FIG.  94.— Syphilitic  ulceration  of  epi-  FIG.  95.— Syphilitic  ulceration  (Turck). 

glottis.     Hypertrophy  of  left  ventricular        a,  b,  c,  remnants  of  epiglottis, 
band  and  ary-epiglottic  fold  (Mackenzie). 

These  deep  ulcers  usually  occur  three  or  four  years  after 
the  primary  sore,  but  they  have  been  known  to  make  their 
appearance  twenty,  thirty,  or  forty  years  later,  without  the 
occurrence  of  intermediate  symptoms. 

The  voice  and  the  respiration  are  usually  more  disturbed 


360  THE   THROAT   AND   NASAL   CAVITIES. 

than  in  the  secondary  stage.  Swallowing  may  become  almost 
impossible  from  destruction  of  the  epiglottis  (Fig.  95).  How- 
ever, there  are  cases  on  record  in  which  this  lesion  has  not 
materially  interfered  with  deglutition.  The  ulcerative  process 
is  often  associated  with  oedema,  and  morbid  growths  frequently 
occur  on  the  inter-arytenoid  fold  or  over  the  arytenoid  carti- 
lages. 

Gummata  are  occasionally  found  in  this  stage.  They  usually 
occur  as  smooth  round  elevations  of  a  yellowish  tint  or  covered 
with  mucous  membrane  of  normal  color.  They  are  generally 
multiple.  These  growths  are  most  frequently  located  on  the 
anterior  surface  of  the  posterior  wall  of  the  larynx.  The  ulcer- 
ations  which  follow  them  are  of  the  most  destructive  kind. 


FIG.  96. — Gumma  (Mackenzie).          .        FIG.  97. — Multiple  gummata  (Mandl). 

As  cicatrization  occurs,  the  larynx  may  be  greatly  distorted 
the  ulcerated  surfaces  may  become  adherent  to  each  other,  and 
sometimes  the  vocal  cords  will  be  bound  together  by  a  web  of 
cicatricial  tissue.    The  resulting  stenosis  may  necessitate  trache- 
otomy. 


Fie.  98. — Web  between  vocal  cords  following  syphilitic  ulceration  (Mackenzie). 

DIAGNOSIS 

The  diagnosis  can  usually  be  easily  made,  excepting  in  the 
cases  of  simple  hyperaemia  already  mentioned.  Deep  ulcera- 
tions  of  the  tertiary  stage  may  be  mistaken  for  the  ulcerations 
of  tuberculous  or  cancerous  disease.  The  distinctive  features 
between  syphilitic  and  tuberculous  laryngitis  were' pointed  out 


SYPHILITIC   LARYNGITIS.  ^ 

when  speaking  of  the  latter  (page  356).  The  essential  points 
in  the  differential  diagnosis  between  this  disease  and  cancer  of 
the  larynx  are  pointed  out  in  the  following  table : 

SYPHILITIC  LARYNGITIS.  CANCER  OF  THE  LARYNX. 

Ulceration  is  often  the  first  sign.  Ulceration  is  generally  preceded  by  a 

morbid  growth. 

Development  of  ulcer  acute,  often  oc-  Development  of  ulcer  slower,  usually 

cupying  but  a  few  days.  requiring  a  few  weeks. 

Often  more  than  one  ulcer.  •  Ulcer  solitary. 

Inflammatory  areola   surrounding  the  Ulcer    surrounded    by    an    areola    of 

ulcer,  not  so  marked  as  in  cancer.  marked  inflammation. 

Ulcers  irregularly  round  or  oval,  and  Ulcer   very   irregular   in   outline,  and 

seldom  more  than  one  fourth  to  one  half        larger  than  syphilitic  ulcers, 
an  inch  in  diameter. 

Ulcers   speedily   improve   under  anti-  No  improvement  results  from  specific 

syphilitic  treatment.  treatment. 

History  of  syphilis  and  usually  absence  Usually,   though  not  always,   the  his- 

of  pain.  tory  of  cancer  in  other  localities.     Severe 

lancinating  pains  are  nearly  always  pres- 
ent. 

TREATMENT. 

The  constitutional  disease  requires  the  exhibition  of  iodide 
of  potassium  or  bichloride  of  mercury  or  the  two  combined. 
It  is  best  to  commence  the  use  of  the  iodide  in  five-grain  doses. 
Its  effects  should  be  watched,  and  when  the  patient  will  bear 
it  the  dose  should  be  largely  increased,  unless  improvement 
speedily  occurs.  In  severe  cases  the  best  results  have  been 
obtained  from  doses  of  ten,  twenty,  thirty,  or  even  sixty  grains, 
given,  largely  diluted,  three  or  four  times  a  day.  Extract  or 
tincture  of  nux  vomica  may  be  given  at  the  same  time  to  pre- 
vent coryza.  Fowler's  solution  may  be  administered  to  prevent 
the  cutaneous  eruption  which  is  likely  to  follow  the  free  use  of 
this  remedy. 

Locally. — Ulcers,  if  simply  indolent,  may  be  touched  with 
some  of  the  strong  stimulant  pigments,  as  iodine,  nitrate  of 
silver,  or  sulphate  of  copper  (Form.  105,  102,  ico).  If  the 
ulcers  are  extending,  they  should  be  cauterized  with  the  solid 
nitrate  of  silver,  with  sulphate  of  copper,  gr.  xx.  ad  fl.  5  i., 
or  acid  nitrate  of  mercury  in  full  strength  or  diluted  with 
two  or  three  parts  of  water,  or  with  the  galvano-cautery. 
Waldenburg  and  others  highly  extol  an  atomized  solution  of 
bichloride  of  mercury,  gr.  ss.  to  gr.  i.  ad  fl.  I  i.,  for  promoting 


362  THE   THROAT   AND   NASAL   CAVITIES. 

the  healing  of  syphilitic  ulcers.  Vicious  adhesions  of  the  vocal 
cords  to  each  other  should  be  broken  up  with  the  cutting  for- 
ceps or  the  galvano-cautery ;  permanent  stenosis  should  be 
treated  by  dilatation.  Dr.  W.  MacNeill  Whistler  reports  two 
cases  of  stenosis  which  he  successfully  treated  by  means  of  his 
almond-shaped  dilator  and  laryngotome.*  Tracheotomy  may 
be  necessary. 

STENOSIS   OF  THE   LARYNX   AND   TRACHEA. 

Stenosis  or  stricture  of  the  larynx  is  most  often  the  result  of 
syphilis.  It  may  follow  chondritis  or  perichondritis,  and  may 
be  due  to  organized  inflammatory  exudation,  cicatricial  con- 
striction, vicious  adhesions,  or  chronic  tumefaction.  Stricture 
of  the  trachea  frequently  occurs  near  its  bifurcation,  but  is  also 
observed  near  its  upper  extremity. 

SYMPTOMS. 

The  symptoms  are  those  due  to  mechanical  obstruction  to 
the  entrance  of  air,  and  they  necessarily  vary  with  the  amount 
of  constriction.  Phonatiou  may  or  may  not  be  impaired. 
Dysphagia  is  sometimes  present  when  the  upper  portion  of  the 
larynx  is  involved.  Inspiration  is  usually  prolonged  and  strid- 
ulous.  If  dyspnoea  is  marked,  it  will  be  followed  eventually  by 
all  the  symptoms  and  signs  of  imperfect  aeration  of  the  blood. 

SIGNS. 

Upon  inspection,  alterations  in  the  larynx  which  diminish  its 
calibre  are  usually  detected.  The  vocal  cords  may  be  partially 
adherent  to  each  other,  the  ventricular  bands  may  be  hyper- 
trophied  or  bound  together,  the  inner  surfaces  of  the  arytenoid 
cartilages  may  have  become  permanently  fixed  to  each  other, 
or  the  epiglottis  may  be  adherent  to  the  aryteno-epiglottidean 
folds.  Sometimes  the  stenosis  is  due  to  submucous  infiltrations 
or  to  hyperchondrosis,  and  in  other  instances  two  or  more  of 
these  conditions  may  be  combined. 

DIAGNOSIS. 

The  diagnosis  rests  partly  upon  the  history  and  partly  upon 
the  laryngoscopic  appearances.  Tracheal  stenosis  cannot  al- 

*  Archives  of  Laryngology,  Vol.  I.,  p.  32^- 


STENOSIS   OF   THE   LARYNX  AND   TRACHEA.  363 

ways  be  detected  by  inspection.  In  such  cases  it  must  be 
diagnosticated  by  the  symptoms  and  by  the  exclusion  of  ob- 
structions in  the  larynx.  Explorations  with  sounds  and  bougies 
may  sometimes  aid  us  in  its  diagnosis. 

TREATMENT. 

Tracheotomy  should  be  performed  to  relieve  the  dyspnoea, 
after  which  efforts  should  be  made  to  dilate  the  canal  by  means 
of  Mackenzie's,  Navratil's,  Schroetter's,  or  Whistler's  instru- 
ments. Schroetter  has  recently  been  very  successful  in  dilating 
strictures  of  the  larynx  by  means  of  hard-rubber  tubes  with- 
out having  first  done  tracheotomy.  These  tubes  are  from 
eight  and  a  half  to  nine  and  a  half  inches  in  length,  and  have 
about  the  same  curvature  as  Mackenzie's  laryngeal  forceps. 

The  laryngeal  portion  of  the  tube  is  somewhat  triangular, 
corresponding  to  the  normal  shape  of  the  glottis,  and  it  is 
slightly  wedge-shaped  at  its  tip,  which  is  supplied  with  fenes- 
tra  through  which  the  patient  may  breathe  when  the  instru- 
ment is  in  position. 

In  the  series  now  used  by  Schroetter  there  are  twelve  of 
these  tubes,  varying  in  size  from  about  three  eighths  to  seven 
eighths  of  an  inch  from  before  backward,  and  from  one  fourth 
of  an  inch  to  five  eighths  of  an  inch  transversely. 

Dr.  J.  D.  Arnold*  describes  the  operation  as  follows:  "The 
tube,  which  is  always  best  introduced  under  the  guidance  of 
the  mirror,  is  grasped  firmly  by  the  middle  and  index  fingers 
above,  and  thumb  below,  and  passed  so  deep  into  the  larynx  as 
to  press  with  its  tip  upon  the  true  cords.  Here  the  operator 
rests  until  the  cords  open  during  inspiration  when,  with  con- 
siderable force,  if  necessary,  the  tube  is  pushed  through  the 
stenosis  into  the  trachea  to  such  depth  that  all  its  fenestra 
shall  be  beyond  the  constricted  portion.  Except  in  cases 
where  dyspnoea  is  a  very  urgent  symptom,  the  mere  passage 
of  the  stricture  is  all  that  should  be  attempted  at  the  first  trial ; 
the  period  of  retention  to  be  prolonged  as  the  parts  become 
more  tolerant  of  the  instrument." 

Subsequently   the   instrument   may  be   introduced   two 
three  times  daily  if  thought  best,  and  it  maybe  allowec 
remain  in  position  from  five  to  thirty  minutes.       

*  Archives  of  Laryngology,  Vol.  II.,  page  231. 


364 


THE   THROAT   AND   NASAL   CAVITIES. 


If  the  cicatricial  tissues  do  not  yield  to  simple  dilatation, 
they  may  be  nicked  with  a  knife  or  with  Whistler's  laryngotome, 
or  touched  with  the  galvano-cautery.  Stenosis  of  the  trachea 


FIG.  99. — Mackenzie's  laryngeal  dilator. 

A,  closed.     B,  open.     The  blades  may  be  separated  by  turning  the  screw  s,  and  the 
extent  of  the  separation  will  be  registered  on  the  dial  d. 

is  not  amenable  to  treatment  unless  the  stricture  is  located  near 
the  upper  part  of  the  tube  and  is  not  extensive,  [n  the  article 
above  alluded  to,  Dr.  Arnold  records  a  case  where  the  same 
laryngologist  successfully  dilated  a  stricture  of  the  trachea  by 
means  of  catheters  without  tracheotomy. 


LECTURE  XXXI. 
DISEASES   OF   THE   LARYNX-Continued. 

LUPUS. 

Lupus  of  the  larynx  has  been  occasionally  detected,  but 
laryngoscopy  reveals  no  special  characteristics.  The  appear- 
ance is  similar  to  that  which  might  be  caused  by  tuberculosis, 
syphilis,  or  carcinoma.  The  diagnosis  must  rest  upon  the 
presence  of  disease  externally. 


FlG.  IOO. — Lupus  of  larynx  (Ziemssen). 


FIG.  loi. — Lupus  of  larynx  (Ttirck). 
a,  b,  epiglottis. 


TREATMENT. 

The  ulcer  should  be  touched  with  the  solid  nitrate  of  silver, 
and  care  must  be  taken  to  cauterize  only  a  small  surface  each 
time.  If  this  caustic  is  too  severe,  milder  remedies  should  be 
employed.  Internally. — Cod-liver  oil  is  highly  recommended 
in  these  cases. 

LEPRA. 

Elephantiasis,  when  involving  the  larynx,  causes  catarrhal 
inflammation,  and  more  or  less  deformity  with  dysphonia  and 
dyspnoea. 

DIAGNOSIS. 

The  diagnosis  is  easily  made,  on  account  of  the  external 
manifestations.  In  the  only  case  which  has  come  under  my 


THE   THROAT   AND   NASAL   CAVITIES. 

observation,  the  mucous  membrane  of  the  larynx  was  of  a 
peculiar  reddish-yellow  color,  and  the  vocal  cords  had  the 
grayish  appearance  which  has  been  described  by  Prof.  Elsberg. 
The  epiglottis,  supra-arytenoid  cartilages,  ventricular  bands, 
and  vocal  cords  were  nodulated,  as  seen  in  the  drawing  (Fig. 
102)  which  I  made  for  Dr.  Hyde  in  illustration  of  the  case.  In 


FIG.  IO2. — Lepra  of  larynx.  Besides  the  irregular  thickening  of  the  epiglottis  and 
ary-epiglottic  folds,  five  distinct  tubercles  can  be  seen  on  the  vocal  cords  and  ventricu- 
lar band,  and  one  is  indistinctly  seen  on  the  anterior  surface  of  the  infraglottic  por- 
tion of  the  larynx. 

some  cases,  the  nodulation,  deformity,  and  ulceration  are 
extensive,  and  differ  considerably  from  the  changes  found  in 
the  case  just  referred  to.  See  Fig.  103. 


FlG.  103. — Leprosy  of  larynx  (Elsberg). 
TREATMENT. 

The  case  reported  by  Dr.  Hyde  was  given  internally  an 
emulsion  of  chaulmoogra  oil  in  gradually  increasing  doses 
from  five  to  sixty  minims  daily.  At  the  same  time,  an  oint- 
ment containing  the  same  oil  was  applied  to  the  surface.  This 
ointment  was  made  of  one  part  of  chaulmoogra  oil  to  four  or 
five  parts  of  lard.  After  several  months  of  this  treatment,  the 
patient  reported  that  his  voice  was  becoming  clearer  and  the 
tubercles  upon  the  skin  were  diminishing  in  size.  Several 


SECONDARY   DISEASES   OF   THE   LARYNX. 

months  later  he  again  reported  constant  improvement.  In  the 
case  of  this  patient's  leprous  daughter,  a  complete  cure  fol- 
lowed the  use  of  this  remedy. 

HYPERTROPHY  OF   THE   LARYNX. 

Dr.  J.  Solis  Cohen  mentions  one  case  to  which  he  has  given 
this  name.  In  that  instance,  all  the  tissues  of  the  larynx 
seemed  hypertrophied,  so  as  to  necessitate  tracheotomy  for  the 
relief  of  dyspnoea.  There  was  no  alteration  in  the  color  of  the 
mucous  membrane. 

TREATMENT. 

No  special  treatment  can  be  recommended. 


SECONDARY  DISEASES  OF  THE  LARYNX. 

The  larynx  is  frequently  involved  in  the  acute  eruptive 
fevers.  I  have  seen  one  case  associated  with  and  evidently 
dependent  upon  chronic  eczema. 

SMALL-Pox. — In  small-pox,  the  laryngeal  mucous  membrane 
may  be  affected  with  a  mild  eruption ;  or  by  severe  inflamma- 
tion with  exudation  and  the  formation  of  false  membrane, 
which  may  have  the  same  effect  as  the  similar  membrane  in 
true  croup. 

MEASLES. — In  measles,  catarrhal  laryngitis  may  precede  the 
eruption  for  a  day  or  two,  or  it  may  occur  when  the  eruption 
has  nearly  disappeared.  In  the  latter  case  it  often  proves 
obstinate,  and,  judging  from  my  own  experience,  it  frequently 
leaves  permanent  impairment  of  the  voice,  due  in  some  cases 
to  thickening  of  the  ventricular  bands. 

In  other  instances,  from  the  third  to  the  sixth  day  after  the 
eruption,  exudative  or  croupy  inflammation  of  the  larynx 
occurs,  which  is  very  likely  to  prove  fatal. 

In  young  children,  the  diagnosis  of  this  form  of  laryngitis 
must"depend  upon  the  history  and  the  symptoms,  but  in  those 
who  are  older  the  laryngoscopic  appearances  may  aid  us. 

SCARLET  FEVER.— Scarlatina  is  sometimes,  though  rarely, 
complicated  with  oedema  or  croupy  inflammation  of  the  larynx, 
which,  in  young  children,  will  be  indicated  only  by  the  symp- 


368  THE   THROAT   AND   NASAL  CAVITIES. 

toms  of  croup  or  oedema ;  in  those  who  are  older  the  condition 
may  be  readily  diagnosticated  by  the  aid  of  the  laryngoscope. 

TREATMENT. 

The  treatment  of  the  secondary  throat  affection  in  these  dis- 
eases is  essentially  the  same  as  that  of  simple  catarrhal  sore 
throat.  Compressed  pills  of  chlorate  of  potassium  are  useful 
in  many  cases,  and  sedative  troches  may  give  great  relief. 
Obstruction  of  the  larynx  calls  for  tracheotomy.  The  primary 
disease  must  receive  our  principal  attention. 

MORBID  GROWTHS. 

Tumors  in  the  larynx  consist  of  growths  of  several  varieties 
similar  to  those  found  in  many  other  portions  of  the  body.  A 
great  majority  of  these  are  benign ;  and  of  these,  the  most  fre- 
quent are  papillary  or  warty  formations  which  constitute  about 
seventy-five  per  cent  of  all  laryngeal  tumors.  Fibrous  tumors 
are  next  in  frequency.  Next  to  these  are  fibro-cellular  growths 
which,  though  constituting  only  five  per  cent  of  all  of  the  intra- 
laryngeal  tumors,  are  more  frequent  than  cystic,  sarcomatous, 
or  lipomatous  tumors,  or  malignant  epithelial  and  encephaloid 
growths. 

SYMPTOMS. 

The  symptoms  caused  by  a  tumor  in  the  larynx  depend 
upon  its  size  and  position,  and  they  are  essentially  the  same 
whatever  its  nature.  The  usual  symptoms,  which  vary  of 
course  with  the  size  of  the  growth  and  the  part  of  the  larynx 
involved,  are :  cough,  dysphonia  or  aphonia,  dyspnoea,  dyspha- 
gia,  and  occasional  pain. 

Cough  is  not  apt  to  be  troublesome  unless  the  growth  is 
large  or  involves  the  glottis,  or  has  a  tendency  to  bleed. 
When  it  does  occur,  it  is  often  paroxysmal  and  of  a  croupy 
character. 

Hoarseness,  or  even  complete  loss  of  voice,  will  occur  when 
the  growth  is  located  on  the  vocal  cords,  or  when  from  its 
position  or  the  concurrent  inflammation  it  interferes  with 
their  free  vibration.  Not  infrequently  the  aphonia  is  inter- 
mittent, coming  or  disappearing  suddenly  with  changes  in  the 
patient's  position. 


MORBID   GROWTHS. 

Dyspnoea  occurs  whenever  the  neoplasm  is  sufficiently  large 
to  materially  obstruct  the  respiratory  passages. 

Dyspkagia. — Difficulty  in  swallowing  is  not  a  common  symp- 
tom, but  it  may  be  .troublesome  whenever  the  tumor  involves 
the  epiglottis  or  posterior  laryngeal  wall,  or  when  it  is  so  large 
as  to  encroach  upon  the  pharynx. 

Pain. — Acute  pain  is  not  common,  although  patients  often 
complain  of  aching  or  discomfort,  as  though  there  were  a  for- 
eign body  in  the  throat,  and  in  occasional  instances  there  are 
severe  paroxysms  of  pain.  In  one  of  the  malignant  cases  which 
have  fallen  under  my  observation,  severe  pain  was  for  a  long 
time  one  of  the  most  prominent  symptoms.  In  some  cases 
which  I  have  treated,  even  of  small  growths  on  the  vocal  cords, 
patients  have  noticed  slight  pain,  especially  during  deglutition. 

SIGNS. 

A  laryngoscopic  examination  will  usually  at  once  reveal  the 
presence  of  the  morbid  growth,  but  it  is  impossible  to  be  cer- 
tain as  to  its  character  until  some  portion  of  it  has  been  sub- 
jected to  microscopic  examination.  Even  then  the  diagnosis  is 
not  always  certain,  for  laryngeal  tumors  of  a  malignant  histo- 
logical  appearance  have  often  possessed  a  non-malignant  history 
from  first  to  last. 


FIG.    104.— Papilloma   of   right   vocal  FIG.  105.— Multiple  papilloma  (Mac- 

cord,  kenzie). 

PAPILLOMATA  are  warty  growths  which  spring  from  the 
mucous  membrane.  They  usually  have  an  irregular,  cauli- 
flower, or  raspberry-like  surface,  of  a  pale  pink  or  whitish  color, 
but  sometimes  they  are  intensely  red.  They  are  usually  about 
the  size  of  a  pea,  but  they  may  not  be  larger  than  a  small  seed ; 
however,  a  few  attain  the  size  of  a  filbert.  These  are  most 
commonly  found  on  the  upper  surface  or  free  margin  of  the 
vocal  cord,  but  they  may  spring  from  its  under  surface  or 
24 


370 


THE    THROAT   AND   NASAL   CAVITIES. 


occasionally  from  other  parts  of  the  larynx.  These  tumors  are 
nearly  always  sessile,  but  occasionally  pedunculated.  The 
surrounding  mucous  membrane  may  be  either  health}-  or  in- 
flamed. 

FIBRQMATA. — Fibrous  tumors,  the  second  in  frequency  of 
occurrence,  are  usually  seen  as  small  round  or  oval  peduncu- 
lated tumors,  of  a  red  or  grayish  color,  attached  to  the  ante- 
rior extremity  of  the  vocal  cord.  They  vary  in  size,  but  seldom 
exceed  the  dimensions  of  a  large  pea.  When  touched  with  a 
probe  they  are  found  firm  and  resisting.  They  are  developed 
from  the  submucous  connective  tissue. 


Fit;.  106  — Fibroma  of  left  vocal  cord. 

FlBRO-CELLULAR  tumors  consist  of  more  or  less  perfectly 
developed  fibrous  growths  having  a  serous-like  fluid  diffused 
through  their  substance.  By  Mackenzie  these  are  classed  as 
soft  fibromata.  These  are  small  pyriform  or  globular  growths, 
having  a  smooth  or  slightly  irregular  surface,  of  a  pale  pinkish 
or  reddish  hue.  They  are  usually  pedunculated,  but  may  be 
sessile.  They  are  generally  attached  to  the  vocal  cords  or 
laryngeal  surface  of  the  epiglottis. 


FIG.     107. — Fibro-cellular    tumor    on 
right  vocal  cord. 


FIG.  108. — Myxoma(  Mackenzie). 


MYXOMATA  or  true  mucous  tumors  are  extremely  rare  in  the 
larynx.     When  found  they  closely   resemble  fibrous  tumors, 


CYSTIC   GROWTHS. 


371 


be 

CYSTIC  GROWTHS  -Cystic  tumors  of  the  larynx  are  usually 
of  a  white  or  reddish  color,  and  surrounded  by  a  zone  of  con- 
gested mucous  membrane.  They  vary  from  the  size  of  a 
millet  seed  to  that  of  a  small  cherry.  They  are  generally 
sessile  and  globular  in  form.  They  usually  grow  from  the 
laryngeal  surface  of  the  epiglottis  or  from  one  of  the  ventri- 
cles. 1  hey  are  ordinarily  filled  with  semi-fluid  sebaceous-like 
material. 


FIG.  109. — Cystic  growth  in  right  ven- 
tricular band. 


FIG.    no.— Cyst   of   epiglottis  (Mac- 
kenzie). 


FASCICULATED  SARCOMATA,  ADENOMATA,  AND  LIPOMATA  pos- 
sess no  characteristic  appearances  and  are  extremely  rare. 


FIG.  in.  — Mixed  sarcoma. 

This  tumor  was  found  in  a  man,  about  fifty  years  of  age,  who  had  been  troubled 
•with  dysphonia  for  about  two  years,  and  with  some  dyspnoea  for  a  few  months.  The 
growth  was  so  firm  as  to  resist  attempts  at  evulsion  or  crushing.  Prof.  I.  N.  Danforth 
made  a  microscopic  examination  of  some  portions  which  I  removed,  and  pronounced  it 
a  mixed  sarcoma.  . 

ANGIOMATA  or  vascular  tumors  are  also  exceedingly  rare. 
They  may  be  recognized  by  their  dark  color  and  their  tend- 
ency to  bleed  when  touched. 

DIAGNOSIS. 

The  affections  most  likely  to  be  mistaken  for  benign  growths 


372 


THE   THROAT   AND   NASAL   CAVITIES. 


in  the  larynx  are :  syphilitic  or  tuberculous  laryngitis,  malignant 
tumors,  lepra,  lupus,  and  fibrous  cartilaginous  or  lymphoid 
outgrowths,  and  eversion  of  the  ventricle. 

Syphilitic  condylomata  are  comparatively  rare  ;  they  generally 
follow  the  inoculation  in  five  or  six  weeks.  They  consist  of 
slightly  raised  irregular  prominences,  of  a  whitish  color,  and 
situated  on  a  congested  mucous  membrane.  The  history  of 
the  case  is  therefore  different  from  that  of  tumors ;  the  promi- 
nences in  syphilis  are  not  so  conspicuous  as  tumors ;  they  are 
situated  on  a  congested  membrane  and  usually  at  the  back  of 
the  larynx,  neither  of  which  features  is  common  with  any  of 
the  tumors  of  which  we  have  been  speaking.  Again,  condy- 
lomata speedily  disappear  under  the  influence  of  astringents 
and  antisyphilitic  treatment. 

Laryngeal Phthisis. — In  this  affection,  small  warty  excrescences 
are  frequently  formed,  but  the  history  of  the  case  and  the 
presence  of  ulcers  should  prevent  errors  in  diagnosis. 

Lepra  appears  never  to  attack  the  mucous  membranes  pri- 
marily, therefore  the  condition  of  the  skin  will  prevent  error. 

Lupus. — In  this  affection,  the  thickening  much  resembles 
that  of  syphilis,  and  it  is  soon  followed  by  destructive  ulcera- 
tion,  in  which  respects  it  differs  from  non-malignant  laryngeal 
tumors. 

Outgroivths  are  at  once  distinguished  from  tumors  by  the 
absence  of  any  demarcation  between  the  growth  and  the  sur- 
rounding tissues. 

Eversion  of  ilie  ventricle  is  a  very  rare  affection,  and  therefore 
not  likely  to  be  mistaken  for  tumors. 

Carcinoma. — It  is  sometimes  extremely  difficult  to  distinguish 
between  non-malignant  and  malignant  tumors  of  the  larynx. 
The  differential  features  will  be  pointed  out  presently  when 
speaking  of  cancer. 

Care  must  be  taken  not  to  confound  these  various  growths 
with  the  fungous  granulations,  which  are  sometimes  observed 
in  ulceration  of  the  larynx.  The  treatment  of  these  growths 
will  be  considered  together  with  that  of  cancer  of  the  larynx. 

CANCER  OF  THE  LARYNX. 
Cancer  of  the  larynx  usually  affects  only  one  side  at  first,  but 


CANCER   OF   THE   LARYNX. 


373 


it  gradually  increases  in  size  until  all  the  surrounding  tissues 
may  become  involved. 

SYMPTOMS. 

Pain,  dyspnoea,  and  dysphagia  are  usually  present  The 
pain  is  generally  confined  to  the  larynx  until  ulceration  has 
taken  place,  after  which  it  may  radiate  to  the  ears,  orbits,  or 
forehead. 

SIGNS. 

Early  in  the  disease,  the  case  may  present  simply  the  signs 
of  catarrhal  inflammation ;  but  soon  a  circumscribed  tumor, 
which  is  more  or  less  regular  in  outline,  appears  beneath  an 
apparently  healthy  mucous  membrane,  which,  however,  soon 
becomes  vascular  or  livid. 


FIG.  112. — Cancer  of  the  larynx. 
This  growth  was  supposed  to  be  a  sim- 
ple papilloma,  but  a  microscopic  examin- 
ation showed  it  to  be  of  a  semi-malignant 
character.  About  four  weeks  after  its 
removal,  the  disease  appeared  in  the 
ventricular  band  and  ary-epiglottic  fold, 
and  ran  a  rapid  course. 


FIG.  113. — Cancer  of  the  larynx. 

This  drawing  was  made  from  the  lar- 
ynx of  a  man,  about  sixty  years  of  age, 
who  had  been  troubled  with  his  throat  for 
about  four  months.  A  diagnosis  of  can- 
cer frightened  the  patient  away,  and  I  did 
not  see  him  again  for  two  months,  by 
which  time  ulceration  had  taken  place  and 
considerable  deformity  had  occurred  from 
the  continued  growth  of  the  tumor. 


As  the  irregular  thickening  progresses,  the  epiglottis  or 
other  portions  of  the  larynx  may  be  crowded  far  from  their 
normal  position,  and  erelong  ulceration  occurs,  with  great 
destruction  of  tissues,  so  that  the  parts  finally  become  almost 
unrecognizable. 

In  the  encephaloid  variety,  the  tumor  appears  as  a  single 
nodule,  which  soon  ulcerates.  Vegetations  then  spring  from 
the  surface  of  the  ulcer,  but  they  do  not  involve  the  sur- 
rounding mucous  membrane  and  the  ulcer  extends  but  slowly. 


374  THE   THROAT   AND   NASAL   CAVITIES. 

In  the  epithelial  variety,  which  is  by  far  the  most  frequent, 
as  soon  as  an  ulcer  occurs  vegetations  spring  up  about  its 
margins,  which  in  their  turn  speedily  ulcerate  and  thus  cause 
rapid  extension  of  the  original  ulcer. 

Scirrhus  at  first  appears  much  like  a  papillary  or  fibrous 
tumor,  but  its  surface  and  the  surrounding  tissues  soon  become 
inflamed,  and  the  larynx  becomes  distorted  by  its  irregular 
growth. 

DIAGNOSIS. 

At  first  the  diagnosis  may  be  very  difficult,  but  the  history  of 
the  case,  the  absence  of  syphilis,  the  patient's  age — past  mid- 
dle life — the  appearance  of  the  growth,  and  in  some  instances 
the  peculiar  lancinating  pains,  render  the  diagnosis  compara- 
tively clear.  The  occurrence  of  an  irregular  dirty  gray  or  red 
swelling  on  one  of  the  ventricular  bands  presently  places  the 
diagnosis  almost  beyond  the  possibility  of  error.  When  ulcer- 
ation  begins,  the  irregular  tumor,  and  the  fungous  character 
of  the  ulcer  which  is  bathed  in  pus  or  bloody  muco-purulent 
matter,  leaves  little  room  for  doubt.  Finally  the  microscopic 
appearances  and  the  failure  of  anti-syphilitic  treatment  exclude 
benign  growths,  syphilis,  and  tuberculosis,  and  make  the  diag- 
nosis certain.  Small  ulcerated  cancers  of  the  epiglottis,  or 
other  portions  of  the  larynx,  may  be  mistaken  for  tuberculous 
or  syphilitic  ulcers  ;  but  as  the  disease  is  usually  secondary  to 
cancer  in  other  situations,  the  history  and  concomitant  symp- 
toms and  signs  will  nearly  always  determine  the  nature  of  the 
case. 

TREATMENT. 

Operative  procedures  are  not  advisable  when  tumors  are 
small  and  cause  the  patient  no  special  inconvenience,  but,  as 
most  of  these  growths  are  caused  by  chronic  catarrhal  inflam- 
mation, we  should  employ  the  treatment  recommended  when 
speaking  of  catarrhal  laryngitis  (page  339).  This  treatment 
will  frequently  cause  a  diminution  in  the  size  of  the  tumor,  and 
it  will  occasionally  effect  a  cure.  Benign  tumors,  which  inter- 
fere with  the  voice  so  as  to  cause  serious  inconvenience,  and 
tumors  causing  dyspnoea,  should  be  removed.  The  operation 
may  be  done  internally  through  the  upper  orifice  of  the  larynx, 
aided  by  the  laryngeal  mirror  ;  or  externally  by  direct  incision  ; 


CANCER  OF  THE  LARYNX. 


375 


or  both  these  methods  may  be  employed.  When  a  laryngeal 
tumor  seriously  interferes  with  respiration,  unless  it  can  be 
promptly  removed,  tracheotomy  must  be  performed  to  prevent 
suffocation.  Tumors,  except  those  of  cystic  character,  may  be 
torn  away  in  many  cases  by  common  laryngeal  forceps  or  by 
tube  forceps.  They  may  be  crushed  and  more  or  less  com- 
pletely torn  away  by  the  same  instruments ;  or  they  may  be 
removed  by  scissors,  guillotines,  knives,  snares,  the  galvano- 


Fic;.  114. — Mackenzie's   common   laryngeal  forceps,     £   ordinary  size.     A,  lateral 
forceps.     £,  antero- posterior  forceps.     C  and  D,  cutting  forceps. 


FlG>  II5. —Mackenzie's  tube  forceps,     i  ordinary  size. 


cautery,  or  cutting  forceps.     After  removal  of  the  growth,  its 
base  should  be  thoroughly  cauterized  to  prevent  repul lulati, 

Cystic  growths  should  be  incised,  emptied  as  compk 
possible,  and  the  sac  thoroughly  cauterized. 

Malignant  growths  are  necessarily  fatal,  and  should  not 
disturbed   unless  they   interfere   with   respiration.     In   man 
cases,  life  may  be   prolonged   by  removing   porti 
growth,  or  by  performing  tracheotomy. 


376  THE   THROAT   AND   NASAL   CAVITIES. 

The  entire  larynx  may  be  extirpated ;  but,  even  if  successful, 
the  operation  can  add  a  few  months  only  to  the  patient's 
miserable  existence,  and  therefore  it  seems  to  me  cruel  to 
counsel  it.  Tracheotomy  usually  lengthens  life  several  months. 


FIG.  116. — Stoerk's  instruments.  A,  ecraseur.  11,  c,  G,  and  H,  guillotines  of  various 
size  and  form.  D,  E,  F,  forceps  blades  of  different  kinds. 

Dr.  Seiler  has  modified  this  instrument,  and  rendered  it  more  universally  useful  by 
substituting  for  the  tube  a  coiled  wire  spring,  which  moves  over  an  internal  rod  of  cop- 
per which  may  be  bent  at  any  angle. 


TRACK EAL   TUMORS. 


EVERSION  OF  THE  VENTRICLES. 

This  is  of  very  rare  occurrence.  I  am  not  aware  that  more 
than  three  such  cases  are  on  record.  One  of  these  was  diag- 
nosticated before  death  by  Dr.  Lefferts,  of  New  York,  but  the 
others  were  not  detected  until  the  autopsy.  Therefore  we  are 
unable  to  give  any  distinctive  signs.  This  condition  is  likely 
to  be  mistaken  for  a  morbid  growth. 

TREATMENT. 

In  the  case  recorded  by  Dr.  Lefferts,  thyrotomy  was  per- 
formed, and  the  everted  sacculus  cut  off  with  scissors. 

TRACHEAL  TUMORS. 

Tumors  in  the  trachea,  near  it  supper  extremity,  may  gener- 
ally be  seen  by  laryngoscopic  examination,  but  it  may  be 
difficult  to  decide  whether  they  are  located  below  the  cricoid 
cartilage  or  in  the  lower  part  of  the  larynx.  Great  care  must 
always  be  observed  in  the  diagnosis  of  disease  of  the  trachea, 
otherwise  we  are  liable  to  be  misled  by  imperfect  reflection  of 
the  light.  A  poor  illumination  may  apparently  reveal  objects 
that  do  not  exist. 


FIG.  117. — Tumor  in  upper  part  of  trachea. 

This  tumor  occurred  in  a  patient  about  sixty  years  of  age,  but  owing  to  the  large  si 
of  his  trachea  it  gave  him  very  little  inconvenience,  and  therefore  he  declined 
any  attempt  made  for  its  removal.     The  symptoms  in  the  case  were  hoai 
moderate  dyspnoea. 

TREATMENT. 

It  is  very  difficult  to  reach  subglottic  tumors  with  the  for- 
ceps introduced  through  the  mouth,  but  it  may  occasr 
be  accomplished.     Tracheal  tumors  must  generally  h 
after  tracheotomy  or  thyrotomy. 


378  THE   THROAT   AND   NASAL   CAVITIES. 


INVOLUTION  OF  THE  TRACHEA. 

Internal  bulging  of  the  trachea  from  external  pressure  causes 
the  appearance  of  a  morbid  growth.  The  diagnosis  will  de- 
pend upon  the  discovery  of  its  cause. 

TREATMENT. 

The  treatment  consists  of  such  remedies  or  operative  pro- 
cedures as  will  remove  the  growth  which  causes  the  compres- 
sion. When  these  are  of  no  avail,  and  dyspnoea  becomes 
urgent,  tracheotomy  may  be  performed,  and  one  of  Konig's 
long  flexible  canulce  introduced. 

TRACHEOCELE. 

This  consists  of  a  hernial  protrusion  of  the  mucous  mem- 
brane of  the  trachea  between  its  cartilaginous  rings.  Several 
cases  have  been  reported  by  Larry,  under  the  title  of  aerial 
goitre.  The  internal  orifice  may  sometimes  be  detected  by 
laryngoscopy. 

TREATMENT. 

Some  mechanical  contrivance  should  be  so  applied  as  to 
prevent  distention  and  growth  of  the  sac. 

FOREIGN    BODIES    IN    THE    LARYNX. 

Foreign  bodies  are  usually  introduced  into  the  larynx  through 
the  mouth  during  deglutition;  but  they  sometimes  enter  through 
wounds,  and  occasionally  they  pass  up  from  the  trachea  or 
oesophagus.  The  foreign  bodies  which  are  most  commonly 
found  in  this  position  are  pins,  fish-bones,  particles  of  food, 
nuts,  shells,  coins,  pebbles,  buttons,  or  artificial  teeth  with  their 
plates. 

SYMPTOMS. 

The  symptoms  vary  according  to  the  size,  shape,  and  loca- 
tion of  the  foreign  body.  If  the  body  becomes  fixed,  and  is 
very  large,  so  as  to  close  the  rima  glottidis,  death  immediately 
follows. 

Smaller  bodies  or  bodies  differently  located  cause  sensations 


FOREIGN   BODIES   IN   THE   TRACHEA. 

of  discomfort  or  pain.  There  will  be  cough  and  more  or  less 
alteration  of  the  voice,  which  may  be  attended  with  suffocative 
paroxysms,  due  to  spasm  of  the  glottis  or  to  inflammation  and 
swelling  caused  by  irritation  from  the  foreign  substance. 

SIGNS. 

Excepting  in  children,  the  position  of  the  foreign  body  can 
usually  be  discovered  at  once  upon  laryngoscopic  examination. 

DIAGNOSIS. 

The  history  of  the  case 'and  the  laryngoscopic  examination 
will  generally  settle  the  question  of  diagnosis.  In  young  chil- 
dren the  history  alone  must  suffice,  and  this  is  sometimes  so 
imperfect  that  the  diagnosis  cannot  be  made. 

Hysterical  patients  often  imagine  the  presence  of  a  foreign 
body  in  the  larynx,  but  in  these  cases  the  history  and  symp- 
toms and  evidence  discovered  by  inspection  will  usually  reveal 
the  true  nature  of  the  disease. 

TREATMENT. 

The  foreign  body  should  be  removed  at  the  earliest  possible 
moment  by  means  of  laryngeal  forceps,  if  time  is  allowed  and 
the  conditions  are  favorable  ;  otherwise  tracheotomy  should  be 
performed  at  once,  to  prevent  suffocation.  After  tracheotomy 
the  foreign  substance  may  be  removed,  sometimes  through  the 
wound  in  the  trachea,  sometimes  per  vias  naturales,  by  the  aid 
of  forceps,  or  occasionally  by  simply  shaking  the  patient  with 
his  head  downward. 


FOREIGN   BODIES   IN   THE   TRACHEA. 
Foreign  bodies  gain  access  to  the  trachea  in  the  same  manner 
as  to  the  larynx.     The  bodies  themselves  are  usually  small, 
otherwise  they  would  be  caught  in  the  larynx. 

SYMPTOMS. 

If  the  body  is  large,  or  if  considerable  fluid  has  entered  the 
trachea  with  it,  speedy  suffocation  may  ensue. 
body  may  remain  in  the  trachea  or  pass  into  one  of  the 
bronchi-usually  the  right-or  into  some  of  the  subdi 
the  bronchus,  where  it  may  remain  for  a  variable  time,  causing 


380  THE   THROAT   AND   NASAL    CAVITIES: 

more  or  less  dyspnoea  and  cough,  or  exciting  inflammation  of 
the  surrounding  tissues. 

SIGNS. 

The  foreign  substance  may  sometimes  be  seen  with  the 
laryngoscope.  If  it  blocks  up  one  bronchus  more  than  the 
other,  diminished  vocal  fremitus  and  a  feeble  vesicular  murmur, 
with  perhaps  sonorous  rales,  will  generall}-  be  detected  over 
that  portion  of  the  lung  which  is  supplied  by  the  obstructed 
bronchial  tube,  or  the  respiratory  murmur  may  be  wholly 
absent  in  this  region. 

DIAGNOSIS. 

The  history  and  symptoms,  taken  in  connection  with  part  or 
all  of  the  signs  just  mentioned,  usually  render  the  nature  of  the 
case  certain.  A  laryngoscopic  examination,  even  though  it 
should  not  enable  us  to  detect  the  foreign  body,  is  very  im- 
portant for  the  purpose  of  excluding  other  affections. 

TREATMENT. 

If  the  symptoms  are  severe,  tracheotomy  must  be  performed 
immediately.  When  the  trachea  has  been  opened,  if  the  lips 
of  the  wound  are  held  apart,  the  offending  material  will  often 
be  coughed  out.  If  it  is  not  at  once  expelled  it  should  be  ex- 
tracted with  forceps,  if  possible. 

Shaking  the  patient,  with  his  head  downward,  will  often  dis- 
lodge the  foreign  body,  and  cause  its  removal.  If  the  dyspnoea 
is  not  great,  this  plan  should  be  tried  before  tracheotomy  :  the 
surgeon  meanwhile  having  everything  in  readiness  for  the 
operation  at  any  instant,  in  case  there  is  spasm  of  the  glottis. 
After  tracheotomy  there  can  be  no  danger  from  spasm  in  this 
attempt  If,  after  opening  the  trachea,  the  object  cannot  be 
secured,  the  lips  of  the  wound  should  be  stitched  to  the  sur- 
rounding tissues,  and  no  canula  introduced. 


LECTURE   XXXII. 
DISEASES   OF   THE   LARYNX— Continued. 

SPASM   OF  THE   LARYNX. 

Synonyms. — Laryngismus  stridulus ;  Spasmus  glottidis ;  Suf- 
focative  laryngismus ;  Spasm  of  the  glottis ;  Spasmodic  croup, 
and  Cerebral  croup. 

This  is  a  condition  in  which  there  is  a  temporary,  complete 
or  incomplete,  spasmodic  closure  of  the  glottis  or  vestibule  of 
the  larynx,  preventing  free  inspiration.  It  is  characterized  in 
the  former  case  by  cessation  of  the  respiratory  movements,  and 
in  the  latter  by  stridulous  respiration,  almost  identical  with 
that  of  true  croup  or  whooping  cough. 

It  is  a  purely  nervous  disease,  and  was  formerly  believed 
always  to  result  from  cerebral  disorders.  It  is  now  known  to 
be  due  also  to  direct  or  reflex  peripheral  irritation  from  a  great 
variety  of  causes,  for  example,  pressure  on  the  recurrent  laryn- 
geal  nerve,  the  presence  of  irritating  substances  in  the  ali- 
mentary canal,  or  irritation  of  the  gums  due  to  dentition. 

SYMPTOMS. 

The  attack  usually  comes  on  suddenly  in  the  night.  The 
child  awakens  in  fright  from  great  dyspnoea  or  temporary  sus- 
pension of  respiration.  After  a  few  respirations  it  cries  out  and 
soon  falls  asleep  as  though  nothing  had  occurred.  In  severe 
cases  the  symptoms  are  more  violent :  the  breathing  suddenly 
becomes  difficult,  inspiration  is  prolonged  and  stridulous,  and 
in  a  few  moments  the  respiratory  movements  cease,  in  conse- 
quence of  the  complete  closure  of  the  glottis ;  the  face,  which 
was  flushed,  becomes  pallid,  and  this  is  speedily  followed  by 
lividity  ;  the  eyes  roll,  the  veins  in  the  neck  become  turgid, 
and  there  are  spasmodic  contractions  of  the  hands  and  feet. 

In  mild  cases  the  attacks  often  do  not  recur  again  until  the 
following  night.  The  severer  the  paroxysms  the  greater  will 


382  THE   THROAT   AND   NASAL   CAVITIES, 

be  the  rapidity  and  violence  with  which  they  succeed  each 
other. 

DIAGNOSIS. 

This  disease  is  not  likely  to  be  mistaken  for  any  other  except 
true  croup,  from  which  it  may  be  diagnosticated  by  the  absence 
of  fever  and  the  intermittence  of  symptoms  between  the 
paroxysms. 

TREATMENT. 

During  the  paroxysm,  flagellation,  or  dashing  cold  water  in 
the  face,  are  the  most  common  remedies. 

To  terminate  the  spasm  and  prevent  its  recurrence,  in  the 
majority  of  cases  nothing  is  better  than  fifteen  or  thirty-drop 
doses  of  the  compound  syrup  of  squills,  which  should  be  repeated 
every  fifteen  minutes  until  vomiting  occurs.  Turpeth  mineral 
is  given  for  the  same  purpose  in  doses  of  half  a  grain  to  two 
grains,  or  even  more.  Teaspoonful  doses  of  powdered  alum 
act  promptly  and  efficiently. 

The  cause  of  the  spasm  must  be  sought  for  and  removed. 
It  is  most  commonly  found  in  some  derangement  of  the  digest- 
ive organs  associated  with  slight  catarrhal  laryngitis.  The 
spasm  may  be  caused  by  an  enlarged  thyrhus  gland,  especially 
in  young  children.  It  has  been  known  to  be  produced  by 
irritation  of  the  prepuce.  It  is  not  infrequently  caused  by 
hysteria  or  cerebral  or  cerebro-spinal  disease.  Subsequent  to 
the  paroxysm,  vegetable  tonics,  cod-liver  oil,  and  the  bromides 
are  generally  beneficial. 


IRRITATIVE  COUGH. 

This  is  a  dry,  hacking,  and  sometimes  paroxysmal  cough, 
apparently  of  nervous  origin. 

SYMPTOMS  AND  SIGNS. 

The  cough  is  most  frequent  in  the  morning.  It  is  usually 
referred  to  the  region  of  the  trachea. 

Hyperaemia  may  or  may  not  be  present.  The  cough  may  be 
associated  with  disorders  of  the  digestive  organs  or  of  the 
uterus,  and  it  is  sometimes  very  violent  during  dentition. 


ANESTHESIA   OF   THE   LARYNX. 

3°3 

TREATMENT. 

Inflammation  of  the  larynx  should  receive  appropriate  treat- 
ment.  Antispasmodics  will  be  required  to  check  the  tendency 
to  cough. 

SPASMODIC  COUGH. 

We  occasionally  observe  a  peculiar  spasmodic  cough,  which 
occurs  independent  of  any  appreciable  lesion,  to  which  this 
name  is  applied.  This  variety  of  cough  is  most  frequent  in 
hysterical  females,  but  it  also  occurs  in  males.  The  cough 
usually  has  a  characteristic  tone,  resembling  the  cry  of  some 
of  the  lower  animals,  most  frequently  the  yelping-  of  a  small 

1  \f  ^  J  I  O 

dog." 

TREATMENT. 

No  very  satisfactory  method  of  treatment  can  be  recom- 
mended, though  electricity  has  proven  effectual  in  some  cases. 

ANESTHESIA  OF  THE  LARYNX. 

This,  as  the  name  indicates,  is  a  loss  of  sensibility  of  the 
mucous  membrane  of  the  larynx. 

It  is  usually  caused  by  diphtheria  or  bulbar  paralysis,  but 
partial  ansesthesia  sometimes  exists  in  hysteria.  The  insensi- 
bility may  be  confined  to  the  supraglottic  mucous  membrane, 
or  it  may  extend  into  the  trachea.  Sometimes  it  is  confined  to 
one  side  of  the  larynx.  It  may  be  partial  or  complete.  In  the 
latter  case,  it  is  usually  associated  with  more  or  less  paralysis 
of  the  depressors  of  the  epiglottis,  which  prevents  proper 
closure  of  this  valve  during  deglutition  ;  consequently  particles 
of  food  find  their  way  into  the  larynx,  from  which,  owing  to 
the  insensibility  of  the  mucous  membrane,  they  are  not  coughed 
up.  These  particles  are  likely  to  descend  into  the  bronchial 
tubes,  where  they  set  up  an  irritation  which  may  eventuate  in 
pneumonia. 

SYMPTOMS. 

Dysphagia  is  commonly  the  only  prominent  symptom. 

*  Cohen,  Diseases  of  the  Throat. 


384  THE   THROAT  AND   NASAL  CAVITIES. 

SIGNS. 

The  laryngeal  mucous  membrane  has  a  normal  appearance, 
but  it  is  found  more  or  less  completely  insensible  when  touched 
with  a  probe. 

TREATMENT. 

Locally. — The  daily  application  for  five  or  ten  minutes  at 
each  sitting  of  galvanic  or  faradic  currents  of  electricity,  suffi- 
ciently strong  to  cause  discomfort  but  not  pain,  has  been 
recommended.  Internally. — Tonics,  especially  strychnia,  are 
indicated.  The  patient  should  be  fed  through  the  oesophageal 
tube,  if  necessary,  to  prevent  food  from  entering  the  larynx. 

HYPER^STHESIA  OF  THE  LARYNX. 

This  consists  of  an  abnormal  sensibility  of  the  mucous 
membrane  of  the  larynx,  or  of  regularly  intermittent  neural- 
gia, unaccompanied  with  visible  changes  in  structure.  This 
abnormal  sensitiveness  of  the  larynx  is  most  frequently  caused 
by  hysteria  or  excessive  use  of  the  voice.  Rheumatism  may 
be  another  cause.  Neuralgia  in  this  locality  is  often  produced 
by  exposure  to  cold. 

SYMPTOMS. 

These  are :  great  irritability  of  the  parts  with  various  sensa- 
tions, as  burning,  pricking,  etc.  There  is  often  the  sensation  as 
of  a  foreign  body  in  the  throat. 

SIGNS. 

There  is  a  normal  appearance  of  the  mucous  membrane  and 
excessive  irritability  and  intolerance  of  instrumental  manipu- 
lation. 

DIAGNOSIS. 

The  diagnosis  will  rest  upon  the  peculiar  intolerance  of 
manipulation  and  the  absence  of  visible  structural  changes. 

TREATMENT. 

Internally. — Remedies  are  indicated  which  are  calculated  to 
overcome  the  constitutional  disorder,  as,  tonics  for  hysteria  ; 
iodide  of  potassium  or  guaiacum  for  rheumatism  ;  also  the 
bromides  for  their  peculiar  local  effect.  Locally. — The  parts 


MOTOR   PARALYSIS. 

3°5 

may  be  brushed  daily  or  on  alternate  days  with  a  solution  ot 
morphia,  carbolic  acid,  and  tannin  (Form.  91). 

\ 

MOTOR  PARALYSIS. 

The  various  forms  of  paralysis  of  the  larynx  may  result  from 
tumefaction  of  the  muscles  or  adjacent  tissues,  or  from  com- 
pression of  morbid  growths  or  foreign  bodies.  They  also 
result  from  deficient  innervation,  which  may  result  from  trau- 
matic injuries,  or  from  other  lesions  of  the  laryngeal  nerves,  or 
from  cerebral  disease. 

Motor  paralysis  from  lesions  of  the  nerve-trunks  may  exist 
alone,  or  it  may  be  associated  with  paralysis  of  sensation.  It 
may  be  partial  or  complete,  and  unilateral  or  bilateral,  and  it 
may  involve  one  or  several  muscles.  The  larnyx  alone  may  be 
involved,  the  pharynx  and  palate  may  be  similarly  affected, 
or  the  disease  may  be  associated  with  general  paralysis. 

Unilateral  paralysis  is  generally  due  to  local  affections,  or  to 
injury  of  the  nerve-trunk. 

Paralysis  affecting  the  muscles  of  both  sides  is  more  often 
the  result  of  cerebral  disease  or  of  functional  disturbance.  In 
order  to  be  able  to  diagnosticate  the  various  forms  of  motor 
paralysis  and  to  detect  their  causes,  you  must  be  familiar  with 
the  origin  of  the  laryngeal  nerves  and  the  arrangement  of  the 
laryngeal  muscles. 

Nerves. — All  of  the  muscles  of  the  larynx — except  the  crico- 
thyroids  and  possibly  the  thyro-epiglottic  and  ary-epiglottic, 
which  are  supplied  by  the  superior  laryngeal  nerve — receive 
their  motor  nervous  supply  from  the  recurrent  laryngeal 
branches  of  the.  pneumogastric  nerve. 

Muscles. — All  of  the  muscles  concerned  in  the  movements  of 
the  larynx,  excepting  the  arytenoideus,  occur  in  pairs. 

They  are  the  crico-arytenoidei  postici,  known  also  as  the 
abductors  of  the  vocal  cords;  the  crico-arytenoidei  laterales 
and  the  single  arytenoideus  muscle  which  are  the  adductors  of 
the  vocal  cords ;  also  the  thyro-arytenoidei  externi  and  interni 
or  vocal  muscles,  sometimes  called  the  laxors  of  the  vocal  cords ; 
and  besides  these  the  crico-thyroidei  or  tensors  of  the  vocal 
cords,  and  two  other  pairs  which  constrict  the  upper  orifice  of 
the  larynx,  viz.,  the  thyro-epiglottici  or  depressors  of  the  epi- 
25 


386  THE,  THROAT   AND   NASAL   CAVITIES. 

glottis,  and  the  ary-epiglottici  or  compressors  of  the  sacculi 
laryngis. 


PARALYSIS    OF   THE    THYRO-EPIGLOTTIC   AND    ARY- 
EPIGLOTTIC    MUSCLES— (Depressors  of  the  Epiglottis). 

This  affection  is  most  commonly  caused  by  diphtheria,  but 
it  also  occurs  in  general  paralysis,  and  it  is  one  of  the  phenom- 
ena of  progressive  bulbar  paralysis. 

SYMPTOMS. 

The  symptoms  are  mainly  due  to  the  escape  of  fluid  or  par- 
ticles of  food  into  the  larynx  during  deglutition,  with  conse- 
quent paroxysms  of  pain,  coughing,  and  dyspnoea.  The  latter 
do  not  occur  if  anaesthesia  is  also  present. 

SIGNS. 

Upon  inspection  with  the  laryngoscope,  the  epiglottis  is  seen 
to  remain  erect  during  the  imperfect  acts  of  deglutition,  which 
may  be  made  with  the  mouth  open  and  the  tongue  protruded. 
When  the  affection  follows  diphtheria,  it  is  usually  associated 
with  paralysis  of  the  palate  or  of  the' pharynx,  and  anaesthesia 
of  the  larynx. 

DIAGNOSIS. 

The  diagnosis  can  be  made  with  accuracy  only  by  laryngo- 
scopic  examination  and  discovery  of  the  signs  just  mentioned. 

TREATMENT. 

The  treatment  indicated  is  usually  the  same  as  that  for  anaes- 
thesia of  the  larynx. 

PARALYSIS    OF     THE      CRICO-THYROID     MUSCLES— (Ex- 
ternal Tensors  of  the  Vocal  Cords). 

This  form  of  paralysis  generally  occurs  on  both  sides,  but  it 
is  occasionally' unilateral.  It  generally  results  from  diphtheria 
or  exposure  of  the  neck  to  cold  draughts,  or  from  overstrain- 
ing the  voice  in  singing  or  shouting,  especially  during  inflam- 
mation of  the  throat.  It  has  been  produced  by  injury  to  a 
small  branch  of  the  superior  laryngeal  nerve  in  ligating  the 


PARALYSIS   OF   THE   CRICO-TH^ROID   MUSCLES.  387 

common  carotid  artery.  Complete  paralysis  of  the  crico- 
thyroid  is  very  rare.  It  is  sometimes  associated  with  paralysis 
of  the  adductors  and  laxors  of  the  cords. 

SYMPTOMS. 

Besides  the  symptoms  due  to  co-existing  anaesthesia,  persons 
affected  with  this  form  of  paralysis  lose  control  of  the  voice, 
so  that  frequently  they  are  unable  to  command  the  high  notes. 
Sometimes  during  ordinary  conversation,  there  is  a  peculiar 
sliding  rise  in  the  pitch  of  the  voice  which  cannot  be  pre- 
vented. Prolonged  use  of  the  voice  is  sometimes  fatiguing  or 
even  painful. 

SIGNS. 

In  moderate  cases,  the  diagnosis  must  rest  largely  on  the 
foregoing  symptoms,  but  in  some  instances  there  is  some  con- 
gestion, and  in  others  a  pearly  translucent  appearance  of  the 
vocal  cords,  which  are  seen  to  be  relaxed  longitudinally,  so 
that  the  glottis  presents  a  wavy  outline  (Fig.  118).  Complete 


FIG.  118. — Bilateral  paralysis  of  the  crico-thyroid  muscles  (Mackenzie). 

paralysis  of  the  crico-thyroid  may  be  easily  detected  by  plac- 
ing the  finger  on  the  outer  portion  of  this  muscle  during  the 
act  of  speaking,  when,  if  paralysis  exists,  there  will  be  absence 
of  tension  of  the  muscle. 

TREATMENT. 

Internally.— -We  should  administer  strychnia  and  other  tonics. 
Locally.— The  daily  use  of  faradic  or  galvanic  currents  of  elec- 
tricity is  sometimes  beneficial.      When   anaesthesia  co-exists, 
food  should  be  introduced  through  the  oesophageal  tube 
prevent  its  passage  into  the  larynx. 


388 


THE   THROAT   AND    NASAL   CAVITIES. 


PARALYSIS     OF 


THE 


THYRO-ARYTENOID     MUSCLES  — 


(Laxors  of  the  Vocal  Cords). 

The  affection  may  be  either  unilateral  or  bilateral.  This 
form  of  paralysis  is  of  common  occurrence.  It  is  often  asso- 
ciated with  paralysis  of  the  crico-thyroid  muscles  and  the 
adductors  of  the  cords.  It  usually  results  from  straining  the 
voice,  especially  when  the  larynx  is  inflamed,  or  during  the 
change  of  voice  at  the  period  of  adolescence. 

SYMPTOMS. 

The  symptoms  are  harshness  and  high  pitch  of  the  voice, 
with  fatigue  and  sometimes  pain  upon  talking.  When  asso- 
ciated with  paralysis  of  other  muscles,  the  voice  may  be  feeble 
or  aphonic. 

SIGNS. 
/ 
Upon  inspection,  the  vocal   cords  are  seen  to  gape  during 

phonation  throughout  their  entire  extent  (Fig.  119).     If  only 


FIG.  119. — Acute  laryngitis.    Paralysis  FIG.  120. — Paralysis  of  the  thyro-aryt- 

of  the  thyro-arytenoid  muscles.  enoid   muscles   and    partial  paralysis   of 

the  arytenoid. 

one  side  is  affected,  the  gaping  will  be  less.  The  vocal  cord 
upon  that  side  will  be  relaxed  and  concave,  and  will  sag  down- 
ward in  the  middle,  but  the  free  edge  of  the  opposite  cord  will 
remain  straight.  When  tho  arytenoid  muscle  is  also  affected 
the  ellipse  will  be  incomplete  at  the  vocal  processes,  as  the 
cartilaginous  portion  of  the  glottis  also  gapes,  causing  the 
appearance  represented  in  Fig.  120. 

DIAGNOSIS. 

The  diagnosis  will  be  readily  made  from  the  symptoms  and 
the  appearance  of  the  vocal  cords  during  phonation. 


BILATERAL   PARALYSIS.  ,gg 

TREATMENT. 

Internally.— We  should  give  strychnia,  and  other  tonics  if 
necessary.  Locally,— Good  results'often  follow  the  use  of  the 
galvanic  or  faradic  currents  for  a  few  moments  daily.  The 
patient  should  carefully  and  systematically  exercise  the  voice. 

BILATERAL    PARALYSIS    OF   THE    LATERAL   CRICO- 
ARYTENOID    MUSCLES— (Adductors  of  the 
Vocal  Cords). 

Synonyms.— Paralysis  glottidis;  Functional  aphonia;  Apho- 
nia. 

This  is  a  condition  in  which,  owing  to  the  non-approxima- 
tion of  the  vocal  cords,  there  is  partial  or  complete  loss  of  the 
voice.  It  is  often  associated  with  paralysis  of  the  arytenoid, 
and  sometimes  with  paralysis  of  the  posterior  crico-arytenoid 
muscles. 

The  affection  is  most  commonly  caused  by  hysteria,  but  it 
frequently  results  from  acute  inflammation,  the  paralysis  re- 
maining after  the  hyperaemia  has  disappeared. 

Not  infrequently  it  follows  excessive  use  of  the  voice  in  pro- 
fessional elocutionists  or  singers.  In  rare  instances  it  is 
observed  as  an  intermittent  affection,  caused  by  malaria,  and  it 
sometimes  results  from  cerebral  lesions. 

SYMPTOMS. 

The  patient  speaks  in  a  fatigued  whisper.  When  the  paral- 
ysis is  partial,  there  is  dysphonia  or  intermittent  aphonia,  and 
no  sound  is  produced  when  the  patient  attempts  to  laugh. 

When  the  paralysis  is  complete,  both  the  voice  and  the 
cough  are  aphonic ;  but  in  most  cases  coughing  and  sneezing 
are  accompanied  with  sound. 

SIGNS. 

The  larynx  is  usually  paler  than  natural,  and  upon  attempts 
at  phonation  the  vocal  cords  remain  in  the  respiratory  position, 
being  but  slightly  approximated  to  each  other.  In  complete 
paralysis,  the  glottis  remains  widely  dilated  without  even  the 
slightest  movement  of  the  vocal  cords  when  an  attempt  is  made 
at  phonation.  In  cases  where  the  abductor  muscles  are  also 


390 


THE   THROAT   AND   NASAL   CAVITIES. 


paralyzed,  the  cords  maintain  the  cadaveric  position  midway 
between  phonation  and  inspiration.  Sometimes  this  form  of 
paralysis  is  associated  with  a  loss  of  voluntary  control  over  the 
diaphragm,  and  then  not  only  is  the  loud  voice  lost,  but  the 
patient  is  also  unable  to  whisper.* 

DIAGNOSIS. 

The  history  and  symptoms  of  the  case,  together  with  the 
respiratory  or  cadaveric  position  of  the  vocal  cords  during 
attempts  at  phonation,  leave  no  room  for  doubt  as  to  the  diag- 
nosis. 

TREATMENT. 

Internally. — We  should  administer  quinine,  arsenic,  iron  and 
strychnia  in  tonic  doses,  with  nutritious  diet.  Locally. — Fara- 
dization of  the  muscles  with  one  electrode  within  the  larynx, 
and  the  other  external,  will  frequently  greatly  expedite  recov- 
ery. 

When  the  patient  has  become  thoroughly  impressed  with  the  remedial  properties  of 
the  treatment,  indifferent  methods  will  often  succeed  in  this  affection;  such  as  inhala- 
tions of  stimulating  vapors,  or  the  simple  introduction  of  the  throat  mirror.  The  cure 
of  all  hysterical  affections  is  greatly  aided  by  strong  mental  impressions,  which  accounts 
for  most  of  the  "  cures  "  performed  by  ignorant  charlatans  and  magnetic  healers. 


UNILATERAL     PARALYSIS    OF     THE     LATERAL    CRICO- 

ARYTENOID  MUSCLE— (Lateral  Adductor  of 

the  Vocal  Cord). 

In  this  form  of  paralysis,  one  cord  is  not  drawn  to  the 
median  line  on  attempted  phonation,  and  therefore  the  voice 
is  much  impaired  or  it  may  be  lost. 

The  affection  usually  results  from  local  injury  of  the  recur- 
rent laryngeal  nerve,  or  from  malignant  disease,  or  from 
compression  of  this  nerve  by  aneurismal  or  other  tumors.  It 
is  occasionally  caused  by  lead  or  arsenical  poisoning,  by 
exposure  to  cold,  by  rheumatism,  phthisis,  and  accidental  or 
surgical  wounds.  When  accompanied  with  paralysis  of  the 
same  side  of  the  tongue  or  palate,  it  originates  in  serious 
cerebral  .disease. 

*  J.  Solis  Cohen's  Diseases  of  the  Throat,  second  edition. 


PARALYSIS   OF   THE   ARYTENOID   MUSCLE.  ^QJ 

SYMPTOMS. 

The  symptoms  found  in  this  affection  are  slight  impairment 
of  the  voice  with  loss  of  volume,  and  in  rare  cases  aphonia. 
The  sounds  produced  by  singing,  coughing,  or  laughing  are 
more  or  less  altered,  and  are  sometimes  the  first  to  be  affected. 

SIGNS. 

In  phonation,  the  affected  cord  remains  at  the  side  of  the 
larynx,  while  its  fellow  is  drawn  to  the  median  line  or,  as  hap- 
pens in  some  instances,  so  far  beyond  that  point  that  the  cords 
meet  at  the  side  of  the  larynx  (Fig.  122).  In  this  instance  the 


FIG.  I2i.  — Unilateral  paralysis  of  the  FlG.  122.— The  same  in  phonation. 

left  lateral  crico-ary tenoid  muscle.  I  )ue  to 
the  pressure  of  an  aneurism  on  the  left 
recurrent  laryngeal  nerve. 

supra-aryteaoid  cartilages  cross  each  other,  the  one  from  the 
sound  side  passing  in  front.  The  mucous  membrane  covering 
the  affected  cord  is  usually  congested.  Signs  of  a  tumor  may 
generally  be  obtained  in  the  upper  sternal  region. 

DIAGNOSIS. 

The  diagnosis  is  at  once  settled  by  a  laryngoscopic  examina- 
tion, but  the  cause  of  the  difficulty  must  be  searched  for  with 
great  care. 

TREATMENT. 

The  cause  must  be  removed  if  possible.  Local  treatment  is 
useless. 

PARALYSIS    OF    THE    ARYTENOID    MUSCLE-(Central 

Adductor  of  the  Cords). 

In  this  condition,  owing  to  the  non-approximation  of  the 
inner  surface  of  the  arytenoid  cartilages  in  phonation,  there 
gapincr  of  the  posterior  or  inter-cartilaginous  porti 


392 


THE   THROAT   AND   NASAL   CAVITIES. 


rima  glottidis,  with  consequent  impairment  of  the  voice.     It  is 
most  frequently  the  result  of  acute  or  subacute  laryngitis. 

SYMPTOMS. 

These  are :  hoarseness,  and  fatigue  in  talking. 

SIGNS. 

Inspection  reveals  a  triangular  opening,  during  phonation, 
at  the  posterior  part  of  the  rima  glottidis.  There  is  usually 
hypersemia  of  the  mucous  membrane  of  the  larynx. 


FIG.  123. — Paralysis  of  the  arytenoid  muscle  (Ziemssen). 
DIAGNOSIS. 

The  diagnosis  is  not  attended  with  difficulty. 

TREATMENT. 

The  treatment  indicated  is  that  for  acute  laryngitis. 


BILATERAL     PARALYSIS    OF     THE     POSTERIOR    CRICO- 
ARYTENOIDS— (Abductors  of  the  Vocal  Cords). 

In  this  condition,  the  vocal  cords  are  not  drawn  aside  during 
inspiration,  but  remain  in  the  median  line,  closing  the  glottis 
and  causing  stridulous  respiration  and  great  dyspnoea,  without 
altering  the  voice.  Sometimes,  associated  with  this  paralysis, 
there  is  a  spasmodic  tendency  in  the  adductors,  which  adds 
greatly  to  the  danger  of  suffocation.  This  affection  is  usually 
caused  by  disease  of  the  central  nervous  system,  but  it  may  be 
produced  by  morbid  processes  which  involve  both  pneumo- 
gastric  nerves,  or  their  branches  the  recurrent  laryngeal 
nerves.  Occasionally  it  is  of  hysterical,  catarrhal,  or  syphi- 
litic origin.  I  have  observed  it  in  one  case  of  cancer,  involving 
the  anterior  wall  of  the  oesophagus  and  implicating  both 


BILATERAL  PARALYSIS  OF  POSTERIOR  CRICO-ARYTENOIDS.     303 

recurrent  laryngeal  nerves.     It  may  depend  upon  simple  atro- 
phy of  the  muscles. 

SYMPTOMS. 

The  symptoms  are  stridulous  respiration,  especially  during 
sleep,  and  great  dyspnoea  on  the  slightest  exertion.  The 
voice  remains  natural  or  suffers  only  slight  alteration,  except- 
ing in  its  force,  which  is  apt  to  be  feeble.  Suffocative  parox- 
ysms occur,  not  only  on  exertion,  but  occasionally  from 
spasmodic  action  of  the  adductors  of  the  cords.  The  cough 
is  croupy.  Inspiration  is  difficult  and  stridulous,  especially 
during  sleep,  but  expiration  is  usually  quiet. 

SIGNS. 

On  inspecting  the  larynx,  the  vocal  cords  are  seen  very  near 
the  median  line.  During  respiration  the  rima  glottidis  will 
measure  from  one  to  two  lines  in  width  (Fig.  124  and  125). 


FIG.  124.— Bilateral  paralysis   of   the  FIG.    125.— Bilateral   paralysis  of  the 

posterior  crico-arytenoid  muscles— Inspi-        posterior  crico-arytenoid  muscles- 
ration,  ration. 

On  inspiration,  the  lips  of  the  glottis  are  sucked  downward  and 
inward  below  their  normal  plane,  and  with  expiration,  they  are 
blown  upward  and  the  glottis  is  somewhat  dilated,  so  that  1 
air  escapes  freely.     The  vocal  cords  and  the  mucous  me 
brane  of  the  larynx  may  be  of  a  normal  color,  or  slightly  c 
gested. 

DIAGNOSIS. 

In  adults,  the  true  nature  of  the  case  is  at  once  suggested  by 
'  permanent  inspiratory  stridor.     The  characteristic  appe; 
of  the  glottis,  on  inspection,  leaves  no  doubt  as  I 
nosis,  excepting  between  this  condition  and  adhcs. 
inner  surfaces  of  the  arytenoid  cartilages,  which  sometim 
closely  resembles  it  that,  in  the  absence  of  a  previous  I 


THE    THROAT    AND   NASAL   CAVITIES. 

the  differential  diagnosis  may  be  impossible.  Spasm  of  the 
adductors  causes  symptoms  which  closely  resemble  those  of 
this  affection,  but  in  cases  of  spasm  the  inspiratory  dyspnoea  is 
temporary  ;  it  is  diminished  instead  of  being  increased  during 
sleep ;  and  the  vocal  cords  are  constantly  varying  in  their  de- 
gree of  adduction  instead  of  being  immobile. 

TREATMENT. 

Tracheotomy  should  be  performed,  unless  widening  of  the 
glottis  can  be  speedily  secured.  This  operation  is  necessary 
to  prevent  suffocation ;  which  is  liable  to  occur  at  any  moment 
from  slight  spasm  of  the  adductors.  If  the  patiejit  cannot  be 
closely  watched,  or  if  the  tendency  to  spasm  is  marked,  the 
operation  should  be,  done  at  once ;  though  under  more  favor- 
able circumstances  it  is  safe  to  delay  it  for  a  short  time,  as  it 
has  been  found  that  some  cases  will  recover  without  opening 
the  trachea. 

Internally. — Strychnia  should  be  employed.  Locally. — Elec- 
tricity should  be  tried,  though  it  is  not  often  beneficial.  When 
catarrh,  hysteria,  or  syphilis  seem  to  be  the  cause,  they  should 
receive  appropriate  treatment^ 


UNILATERAL    PARALYSIS    OF   THE    POSTERIOR    CRICO- 

ARYTENOID    MUSCLE  (Abductor  of  the 

Vocal  Cord). 

In  this  affection,  one  vocal  cord  remains  in  the  median  line 
during  inspiration,  with,  consequent  dyspnoea  and  stridulous 
.respiration.  The  affection  is  due  to  lesions  similar  to  those 
which  cause  bilateral  paralysis ;  but  it  most  frequently  results 
from  peripheral  causes,  as,  for  example,  catarrhal  inflammation, 
or  the  implication  of  one  pneumogastric  or  recurrent  lar.yn- 
geal  nerve  by  malignant  disease,  aneurisms,  or  other  morbid 
growths. 

SYMPTOMS. 

The  symptoms  are  :  obstructed  inspiration,  st.ridor,  and  dysp- 
noea, with  very  slight  alteration  of  the  voice.  There  are  also 
present  more  or  less  irritative  fever  and  the  symptoms  of  the 
disease  which  has  caused  the  paralysis. 


ANCHYLOSIS   OF   THE   ARYTENOID  CARTILAGES.  395 

SIGNS. 

On  inspection,  the  affected  cord  is  seen  to  remain  stationary 
at  or  near  the  middle  line,  while  the  movements  of  the  other 
cord  are  normal  or  slightly  excessive. 

DIAGNOSIS. 

The  symptoms  and  laryngoscopic  appearances  leave  no  que"s- 
tion  about  the  diagnosis. 

TREATMENT. 

The  cause  should  be  sought  for,  and  if  possible  removed. 
Locally. — Faradism  and  galvanism  should  be  resorted  to.  In 
applying  electricity  within  the  larynx,  the  electrodes  shown  in 
Figures  126  and  127  will  be  found  most  convenient. 


FIG.  126. — Mackenzie's  laryngeal  electrodes. 


FIG.  127.— Ziemssen's  double  and  single  electrodes. 

ANCHYLOSIS   OF   THE   ARYTENOID   CARTILAGES. 
This  is  a  rare  affection,  of  which  only  a  few  cases  have  been 
recorded.     The  diagnosis  is  likely  to  be  attended  with  great 


396  THE   THROAT   AND   NASAL   CAVITIES. 

difficulty,  as  the  affection  may  closely  simulate  paralysis,  either 
of  the  abductors  or  of  the  adductors  of  the  vocal  cords.  The 
affection  should  be  suspected  whenever  we  find  immobility  of 
one  or  of  both  cords,  with  distortion  of  the  cartilages.  It 
should  always  be  looked  for  when  patients  convalescing  from 
typhoid  fever  complain  of  the  symptoms  of  laryngeal  disease. 

TREATMENT. 

If  this  condition  interferes  with  respiration,  attempts  should 
be  made  at  dilatation  of  the  larynx,  though  they  are  likely  to 
be  unsuccessful. 

ATROPHY   OF   THE   VOCAL   CORDS.* 

This  is  extremely  rare,  and  so  far  has  not  been  proved  by 
post-mortem  evidence.  When  there  is  wasting,  the  cords  may 
have  merely  a  shrunken  appearance,  or  they  may  be  so 
shrunken  that,  although  there  is  nothing  to  prevent  inspec- 
tion of  the  glottis,  they  cannot  be  brought  into  view. 

*  Mackenzie's  Diseases  of  the  Throat  and  Nose. 


LECTURE    XXXIII. 
DISEASES   OF   THE   NASAL   PASSAGES. 

HAY   ASTHMA. 

Synonyms. — Hay  fever ;  Rose  cold  ;  Autumnal  catarrh. 

Hay  asthma  is  considered  with  diseases  of  the  nose,  because 
its  most  prominent  and  persistent  symptom  is  due  to  irritation 
of  the  nasal  mucous  membrane. 

This  affection  usually  attacks  its  victims  annually,  at  the 
same  time  of  the  year,  and  frequently  on  the  same  day  of  the 
month.  It  may  occur  in  the  spring  or  summer,  but  it  is  far  the 
most  common  in  the  latter  part  of  August  or  during  the  month 
of  September.  It  usually  continues  about  six  weeks.  The 
disease  is  characterized  by  congestion  or  inflammation,  of  the 
mucous  membranes  of  the  nasal  passages,  frontal  sinus,  and 
throat;  and  often  of  the  conjunctivas  and  bronchial  mucous 
membrane. 

SYMPTOMS   AND   SIGNS. 

The  prominent  features  of  this  affection  are  frequent  and 
violent  sneezing,  a  profuse  watery  secretion  from  the  nasal 
mucous  membrane,  and  more  or  less  asthmatic  dyspnoea. 

DIAGNOSIS. 
The  diagnosis  is  based  on  the  history  and  symptoms. 

TREATMENT. 

Irrigating  the  nasal  cavities  with  a  solution  of  quinine,  gr. 
ij.  to  3  i.  of  water,  two  or  three  times  daily,  will  cure  some 
cases  and  benefit  others.  Relief  will  be  obtained  in  other  cases 
by  insufflation  of  a  powder  composed  of  morphia,  one  part ; 
quinine,  one  part ;  bismuth,  twenty  parts,  and  acacia,  thirty- 
eight  parts.  A  weak  galvanic  current  is  said  greatly  to  relieve 
the  frontal  headache  in  some  cases.  The  ordinary  treatment 
for  asthma  will  more  or  less  relieve  the  dyspnoea.  Determma- 


:    ,v  THE  THROAT  AXD  XASAL  CAVITIES, 

tion  on  the  part  of  the  patient  not  to  sneeze  or  use  the  hand- 
kerchief, except  to  gently  wipe  the  nose,  will  greatly  benefit 
nfld  cases.  Sneezing  may  be  prevented  by  pressing  firmly  on 
the  upper  fip  when  the  inclination  is  felt. 

The  most  effective  remedy  is  change  of  climate.  From  this 
locality  patients  usually  go  to  the  northern  parts  of  Michigan 
or  of  Wisconsin,  or  to  Minnesota,  where  they  obtain  complete 
from  the  disease.  Sometimes  a  slight  change,  as 


from  the  city  to  the  country,  or  vice  TXTSO^  is  sufficient. 


.  —  Acute  cold  in  the  head;  Acute  nasal  catarrh; 
Acute  rhinitis. 

This  is  an  acute  inflammation  of  the  mucous  membrane  of 
the  nasal  passages,  which  is  usually  caused  by  exposure  to 
cold  ;  or  to  the  atmosphere  of  overheated  and  poorly  ventilated 
rooms. 

The  inflammation  at  first  causes  engorgement  of  the  mucous 
membrane,  with  swelling  and  dryness,  which  is  followed  in  a 
few  hours  by  a  profuse  thin  secretion.  After  two  or  three 
days  the  secretion  becomes  thicker  and  muco-purulent.  " 

SYMPTOMS. 

Irritation  or  pain  and  fullness  of  the  nasal  passages,  with  more 
CM*  less  loss  of  the  sense  of  smell  and  taste  are  present.  There 
is  some  anorexia,  and  often  considerable  fever,  especially  if  the 
extends  to  the  throat. 


SIGXS. 

The  mucous  membrane  is  swollen  and  congested. 

DIAGNOSIS. 

The  history,  symptoms,  and  signs  are  too  familiar  to  every 
one  to  permit  of  error  in  diagnosis. 

TREATMESrr. 

At  the  onset  it  may  usually  be  aborted  by  the  administration 
of  quinine,  gr.  x.  ;  Dover's  powder,  gr.  x.  ;  a  hot  sling  at  bed. 
time  ;  carbonate  of  ammonium,  gr.  xxv.  ;  or  tincture  of  bella- 
donna, m  XX.  Inhalations  of  the  fumes  of  iodine  from  the 


CHRONIC  CORYZA. 

399 

metalloid,  of  tincture  of  camphor,  or  of  camphor  and  iodine, 
of  carbolic  acid,  or  of  nascent  chloride  of  ammonium  quite 
continuously  used  for  two  or  three  days  will  often  cut  the  cold 
short.  Smearing  the  nasal  passages  with  vaseline  will  be  very 
useful  in  soothing  the  irritation.  When  the  disease  has  be- 
come fully  established,  the  remedies  indicated  consist  of  small 
doses  of  morphia,  grs.  ^  to  ^  or  of  tincture  of  belladonna, 
iq,  L,  or  tincture  of  aconite,  H  SS.-L,  every  half-hour  for  three 
or  four  hours,  and  subsequently  less  frequently;  conjoined 
with  quinine,  gr.  ij.,  and  chlorate  of  potassium,  gr.  v.  to  x^ 
every  three  hours. 

Warm  drinks  and  other  means  of  promoting  diaphoresis* 
and  laxatives,  generally  hasten  the  recovery. 

CHROXIC  CORYZA. 

Synonyms.  —  Chronic  nasal  catarrh ;  Chronic  rhinorrhoea. 
This  is  a  chronic  inflammatory  condition  of  the  nasal  mucous 
membrane,  characterized  by  thickening  of  the  membrane  with 
more  or  less  abundant  muco-purulent  secretion,  which  escapes 
through  the  nostrils  and  pharvnx. 

It  is  often  the  result  of  inherited  syphilis  or  scrofula,  and  in 
such  cases  ulceration  usually  occurs. 

Occasionallv  the  mucous  membrane  becomes  atrophied,  as 
the  result  of  prolonged  inflammation. 

SYMPTOMS- 

The  patient  complains  of  obstructed  nasal  respiration  with 
abundant  muco-purulent  discharge,  from  the  nostrils,  or  into  the 
throat.  The  discharges  are  often  streaked  with  blood,  and  if 
allowed  to  desiccate  and  decompose  in  the  nostrils  they  be- 
come extremely  offensive.  When  the  discharges  are  offensive, 
the  affection  is  termed  ozzena. 

SIGNS. 

Upon  inspection  of  the  nasal  cavities,  anteriorly  and  poste- 
riorly, the  mucous  membrane  is  found  congested  and  thick- 
ened'uniformly  or  in  patches,  and  more  or  less  covered  with 
altered  secretions.  When  the  cavities  have  been  thoroughly 
cleaned,  ulcerations  may  often  be  detected,  and  somet 
warty  crrowths  or  polypoid  excrescences  will  be  discovered. 


400 


THE   THROAT   AND   NASAL   CAVITIES. 


DIAGNOSIS. 


No  difficulty  can  be  experienced  in  the  diagnosis,  though 
care  must  be  exercised  to  ascertain  whether  it  is  simply  an 
idiopathic  inflammation,  or  whether  it  is  dependent  on  the 
syphilitic  or  strumous  diathesis. 

TREATMENT. 

It  is  all-important  in  this  affection  to  employ  such  constitu- 
tional remedies  as  may  be  necessary  to  improve  the  patient's 
general  condition.  Locally, — The  parts  should  be  cleansed 
once  or  twice  daily  by  means  of  the  nasal  douche,  or  by  snuff- 
ing fluids  into  the  nasal  cavities;  using  weak  solutions  of  the 
chloride  or  carbonate  of  sodium,  for  example  half  a  teaspoonful 
or  a  teaspoonful  to  the  pint  of  tepid  water.  In  using  the 


FIG.  128. — Nasal  douche. 


FIG.  129. — Travelers'  nasal  douche. 


nasal  douche,  the  patient  should  exercise  great  care  not  to 
swallow  during  the  operation,  as  this  act  might  allow  some  of 
the  fluid  to  pass  into  the  Eustachian  tubes  and  cause  inflam- 
mation of  the  middle  ear. 

The  parts  having  been  thoroughly  cleansed,  sedative  or 
stimulating  applications  should  be  made  according  to  the  con- 
dition of  the  mucous  membrane — sedative  applications  when 
the  parts  are  irritated  and  sore,  and  stimulating  applications 
when  the  inflammation  is  clearly  of  an  indolent  character. 

The   treatment   should   always   be   commenced    with    mild 


CHRONIC   CORYZA. 


s 


401 
very 


FIG.  130. — Spray  producer  for  applications 
to  nasal  passages  or  fauces. 


FIG.  131. — Atomizer  tubes. 


FIG.  132. — Hard-rubber  tube  for  insufflator. 


FIG  133. — Insufflator.  A,  bulb.  B,  powder  in  glass  tube  ready  for  insufflation. 
D  and  £,  short  bends  for  posterior  nares.  F,  a  piece  of  rubber  tubbing,  which  h«s 
been  slipped  over  the  glass  to  prevent  accident  in  case  the  glass  tube  should  be 
broken  while  in  the  throat. 

For  a  sedative  effect  we  may  use  vapors  or  sprays  of  conium, 
opium,    stramonium,  or  benzoin'  (Form.  37  and  39);  or  oint- 
26 


1=.  u  v  «c  I I 


k  1  h 


4O2 


THE   THROAT   AND   NASAL  CAVITIES. 


ments  of  the  same  or  of  iodoform  ;  or  powders  of  bismuth,  mor- 
phia, or  iodoform  (Forms.  111-113).  Smearing  the  parts  with 
vaseline  protects  them  from  the  irritating  effects  of  the  atmos- 
phere and  thus  favors  recovery. 

When  stimulation  is  required,  we  will  find  useful  :  vapors 
of  iodine,  chloride  of  ammonium,  camphorated  tincture  of 
opium,  tar,  or  oil  of  white  pine  (Form.  43-56).  Sprays  of 
the  mineral  astringents,  as  sulphate  or  chloride  of  zinc,  sul- 
phate of-  copper,  or  alum  in  weak  solutions  may  be  employed, 
or  the  same  remedies  may  be  applied  with  a  brush  (Form. 


Stimulating  powders  may  be  blown  into  the  nasal  cavi- 
ties, preferably  through  the  posterior  nares.  The  best  of 
these  powders  consists  of  hydrastine,  one  part,  to  acacia  or 
starch,  three  parts,  by  bulk.  This  should  be  employed  in  such 
quantities  that  from  half  a  grain  to  one  grain  of  the  hydrastine 
will  be  used  at  each  application.  The  applications  should  be 
repeated  at  intervals  of  two  or  three  days  or  more,  according 
to  the  effect.  Care  should  be  taken  to  allow  the  stimulating 
effects  of  an  application  to  subside  before  its  repetition.  In 
the  mean  time  mildly  stimulating  sprays  may  be  used  by  the 
patient  at  home. 

When  the  mucous  membrane  is  much  thickened  over  the 
turbinated  bones,  it  must  be  partially  destroyed.  For  this 
purpose  the  galvano-cautery,  nitrate  of  silver,  acid  nitrate  of 
mercury,  nitric  acid,  chromic  acid,  or  acetic  acid  may  be  em- 
ployed. Of  these  the  glacial  acetic  acid,  as  recommended  by 
Bosworth,  I  have  found  most  satisfactory.  It  is  applied  by 
means  of  a  pledget  of  absorbent  cotton  wrapped  on  a  flattened 
probe.  The  application  causes  considerable  pain,  but  this  may 
be  immediately  relieved  by  a  spray  or  douche  of  some  mild 
alkaline  solution. 

Dobell's  solution  will  be  found  convenient  for  this  purpose. 
It  contains  one  grain  of  carbolic  acid,  two  grains  each  of  borate 
and  bicarbonate  of  soda,  and  one  drachm  of  glycerine,  with 
seven  drachms  of  water  in  each  ounce  of  the  solution. 

The  caustic  application  may  be  repeated  in  from  seven  to 
fourteen  days.  Ulcerated  surfaces  may  be  dusted  over  with 
iodoform,  or  touched  with,  solutions  or  the  solid  stick  of 
nitrate  of  silver.  If  these  applications  do  not  cause  them  to 


ADENOMA  OF  THE  VAULT  OF  THE  PHARYNX.     403 

heal,  they  should  be  slightly  seared  from  time  to  time  with  the 
galvano-cautery. 


ADENOMA  AT  THE  VAULT  OF  THE  PHARYNX. 

Synonyms. — Hypertrophy  of  the  pharyngeal  tonsil ;  Adenoid 
vegetations  in  the  naso-pharyngeal  cavity. 

This,  as  the  name  implies,  consists  of  increased  growth  in 
the  glandular  tissue  at  the  upper  part  of  the  pharynx.  It  is 
characterized  by  an  increased  secretion  which  mostly  finds  its 
way  behind  the  palate  into  the  mouth.  There  is  also  more  or 
less  obstruction  to  nasal  respiration,  with  a  frequent  desire  to 
snuff,  hawk,  or  clear  the  throat. 

SYMPTOMS. 

The  symptoms,  besides  those  just  enumerated,  are  a  sensa- 
tion of  fulness  in  the  posterior  nares,  and  expectoration  of 
small  masses  of  tenacious  mucus ;  which  is  sometimes  streaked 
with  blood.  There  is  also  more  or  less  alteration  of  the  voice 
in  pronouncing  nasal  tones. 

SIGNS. 

On  rhinoscopic  inspection  the  deep-red  hypertrophied 
glandular  tissue  can  be  seen  at  the  vault  of  the  pharynx. 
Sometimes  it  has  the  appearance  of  an  hypertrophied  tonsil, 
and  at  other  times  it  hangs  in  pendent  masses  (Fig.  133).  The. 


FIG.  133.— Rhinoscopic  view  of  vegetations  at  vault  of  pharynx  (Cofien). 

palate  is  often  thickened,  and  chronic  follicular  pharyngitis 
usually  co-exists.     The  finger  passed  behind  the  palate  feels 
*  .1 


the  growth. 


THE   THROAT   AND   NASAL   CAVITIES. 
DIAGNOSIS. 

Thorough  inspection  and  palpation  leave  no  chance  for  error 
in  diagnosis. 

TREATMENT. 

Locally. — Astringents  and  caustics  may  be  employed  with 
some  benefit ;  but  removal  of  the  offending  mass  with  forceps, 
or  better  still  with  the  galvano-cautery,  is  much  the  most 
effective  treatment. 

SUBMUCOUS    INFILTRATIONS    AT    THE    SIDES    OF    THE 

VOMER. 

This  is  a  very  common  affection,  characterized  by  more  or 
less  difficulty  in  nasal  respiration  and  increased  secretion.  It 
is  often  associated  with  adenoma  of  the  vault  of  the  pharynx 
and  chronic  inflammation  of  the  pharyngeal  mucous  membrane. 
The  altered  mucus  collects  in  the  posterior  nares  and  "drops 
into  the  throat"  or  causes  frequent  hawking.  The  symptoms 
are  those  of  post-nasal  catarrh.  Inspection  by  the  aid  of  the 
rhinoscope  reveals  a  yellowish-white  puffiness  on  one  side 
or  on  both  sides  of  the  vomer,  near  its  posterior  margin  (Fig. 


-FlG.  134. — Submucous  infiltration  at  sides  of  vomer  (Cohen). 
DIAGNOSIS. 

There  can  be  no  difficulty  in  the  diagnosis  when  pharyngeal 
affections  have  been  excluded  and  the  characteristic  appear- 
ances just  mentioned  are  discovered. 

TREATMENT. 

We  should  destroy  the  cedematous  tissue  by  means  of  the 


THICKENING  OF   THE   SEPTUM. 

4°  5 

galvano-cautery,  or  we   may  tear  it  off  with   forceps.    The 
former  is  most  effective.     Astringents  have  little  effect. 

DISTORTION   OF   THE   NASAL  SEPTUM. 

The  septum  may  be  bent  so  far  to  one  side  as  completely  to 
obstruct  the  corresponding  nasal  passage  and  proportionately 
interfere  with  respiration  through  the  nose.  This  condition, 
when  extreme,  crowds  the  end  of  the  nose  to  one  side.  The 
affection  seems  to  be  caused  by  increased  growth  of  the  edges 
of  the  cartilaginous  septum. 

DIAGNOSIS. 

Inspection  reveals  a  convexity  of  the  septum  on  one  side, 
with  a  corresponding  concavity  in  the  opposite  passage. 

TREATMENT. 

We  should  dilate  the  occluded  passage  by  tents  of  compressed 
sponge,  metallic  tubes,  or  tubes  of  laminaria.  If  these  measures 
fail,  we  may  perforate  the  septum  so  that  air  can  pass  from  one 
nasal  passage  into  the  other.  M.  Chassaignac  recommends  sub- 
periosteal  excision  of  a  sufficient  amount  of  the  septum  to 
allow  it  to  be  easily  crowded  into  its  normal  position,  where  it 
should  be  retained  until  healing  is  complete,  by  means  of  a  bit 
of  sponge  in  the  nasal  passage. 

THICKENING  OF  THE  SEPTUM. 

Aside  from  the  abnormal  growth  from  the  borders  of  the 
septum,  which  sometimes  causes  its  deflection  to  one  side,  we 
frequently  observe  thickening  near  its  lower  border,  due  to- 
bony  or  cartilaginous  outgrowth.  I  have  often  observed  this 
condition  in  patients  affected  with  chronic  coryza. 

DIAGNOSIS. 

Inspection  shows  a  more  or  less  prominent  protuberance  of 
one  or  both  sides  of  the  septum.  When  only  one  side  is 
affected,  no  corresponding  concavity  is  seen  in  the  opposite 
passage.  This  outgrowth  usually  extends  along  the  inferior 
margin  of  the  septum  for  half  or  three  quarters  of  an  inch,  and 
upward  from  a  quarter  to  three  eighths  of  an  inch. 


406  THE   THROAT   AND   NASAL  CAVITIES. 

thickening  of  the  septum  at  the  most  prominent  part  may 
reach  three  eighths  of  an  inch  or  more.  Palpation  with  the 
finger  or  a  probe  shows  that  this  prominence  is  not  due  to  sub- 
mucous  oedema. 

TREATMENT. 

I  know  of  no  local  applications  which  either  diminish  the 
size  of  the  outgrowth  or  check  its  increase. 

The  associated  coryza  should  receive  appropriate  treatment. 
If  the  outgrowth  becomes  so  large  as  materially  to  obstruct 
respiration,  the  mucous  membrane  may  be  everted  and  the 
excrescence  chiseled  away.  Internally. — Internal  treatment  is 
usually  indicated  by  the  fact  that'  the  affection  is  most  fre- 
quently the  result  of  rachitis,  scrofula,  or  constitutional 
syphilis. 

NASAL    ABSCESS. 

This  is  usually  found  near  the  anterior  nares,  located  either 
on  the  septum  or  in  the  alae.  It  may  be  an  ordinary  furuncle, 
it  may  be  the  result  of  idiopathic  or  traumatic  inflammation  of 
the  submucous  tissues,  or  it  may  be  caused  by  the  breaking- 
down  of  syphilitic  gummata. 

DIAGNOSIS. 
The  diagnosis  is  attended  with  little  or  no  difficulty. 

TREATMENT. 

We  should  use  warm  anodyne  or  astringent  applications,  and 
the  pus  should  be  evacuated. 


SYPHILITIC   AFFECTIONS   OF   THE    NARES. 

Secondary  or  tertiary  syphilis  may  be  manifested  in  this 
situation.  It  causes  swelling  and  ulceration  of  the  parts,  and 
there  is  a  profuse  fetid  discharge  from  the  nose.  Sometimes 
abscesses  are  formed.  In  many  cases  there  is  serious  destruc- 
tion of  tissue  with  deformity  of  the  organ. 

Secondary  symptoms  are  usually  attributed  to  mucous 
patches,  and  are  not  often  attended  with  ulceration.  This 
condition  causes  an  abundant  greenish-yellow  discharge,  espe- 


STENOSIS    OF   THE   NASAL   PASSAGES.  407 

cially  during  the  day-time,  with  pain  and  obstruction  of  the 
nares. 

Ulcerations,  either  in  the  secondary  or  tertiary  stages, 
render  the  discharges  and  breath  very  offensive. 

DIAGNOSIS. 

The  affection  is  liable  to  be  mistaken  for  scrofulous  affections, 
from  which  it  can  only  be  distinguished  by  the  history,  the 
concomitant  signs,  and  the  results  of  treatment. 

TREATMENT. 

Internally. — Our  treatment  should  be  antisyphilitic,  viz., 
iodide  of  potassium  freely,  and  bichloride  of  mercury  with 
such  tonics  as  seem  necessary  in  individual  cases.  Locally. — 
The  parts  should  be  kept  clean  by  means  of  some  form  of 
nasal  douche.  Ulcers  may  be  touched  with  acid  nitrate  of 
mercury  or  the  galvano-cautery. 

STENOSIS  OF  THE  NASAL  PASSAGES. 

This  results  from  various  causes,  but  most  frequently  from 
hypertrophy  or  an  cedematous  condition  of  the  mucous  mem- 
brane covering  the  turbinated  bones ;  or  from  deflection  of  the 
septum  narium. 

DIAGNOSIS. 

The  diagnosis  may  be  readily  made  by  inspection.  Upon 
posterior  rhinoscopy  the  tissues  covering  the  inferior  or  mid- 
die  turbinated  bones,  or  both,  will  often  be  found  so  thickened 
as  to  nearly  or  completely  obstruct  the  posterior  nares. 

TREATMENT. 

The  treatment  varies  with  the  cause  of  the  affection.     If  it 
results  from  deflection  of  the  septum,  this  must  be  straighte 
or  perforated.     If  it  results  from  thickening  of  the  mucous 
membrane,  the  nasal  cavities  may  be  dilated  by  silver  tubes, 
spono-e-tents,  or  by  tubes  of  laminaria,  as  recommendc 
Cohen;  but  simple  dilatation  usually  gives  only  temporary 
relief      The  most  effectual  method  of  treatment  is  to  desl 
the  redundant  tissue,  and  to  prevent  its  renewal  by  mo 
less   continuous   use  of   mineral  astringents,  such  as 
mended  in  speaking  of  chronic  coryza. 


THE   THROAT   AND   NASAL   CAVITIES. 

When  the  turbinated  bones  are  moderately  enlarged,  cauteri- 
zation with  strong  acetic  acid*  and  the  use  of  astringents,  as 
above,  will  be  found  most  satisfactory  ;  but  if  the  posterior 
nares  are  much  obstructed  by  the  swollen  tissue,  this  must  be 
removed  by  some  more  radical  operation.  The  oedematous 
tissue  may  be  torn  off  with  forceps,  but  this  is  a  bloody  and 
very  painful  operation.  It  may  be  removed  by  Jarvis'  wire 
snare,  but  patients  inform  me  that  this  also  is  exceedingly 
painful.  It  may  be  removed  by  the  galvano-caustic  loop. 
This  latter  operation  I  have  performed  several  times  with  very 
satisfactory  results.  This,  like  the  preceding  operations, 
causes  considerable  pain,  but  it  is  only  temporary,  and  it  may 
be  promptly  relieved  by  a  weak  alkaline  spray,  it  shpuld  not 
be  forgotten  that  erysipelas  may  occasionally  follow  any  of 
these  operations,  though  it  is  not  a  frequent  accident. 


FOREIGN  BODIES  IN  THE  NASAL  PASSAGES. 

Children  often  introduce  into  the  nostrils  pebbles,  buttons,, 
coins,  kernels  of  corn,  beans,  and  the  like  ;  where  they  may 
remain  for  months,  or  even  years,  causing  an  offensive  dis- 
charge and  obstruction  to  nasal  respiration.  The  foreign 
substance  may  become  incrusted  with  the  calcareous  salts  in 
the  secretions,  and  thus  form  the  nucleus  of  a  calculus. 

SYMPTOMS. 

We  find  as  the  most  prominent  symptoms :  obstruction  to- 
nasal  respiration,  an  offensive  discharge,  loss  of  the  sense  of 
smell,  and  alteration  of  the  voice.  Pain  is  present  if  the 
foreign  body  is  large  or  irregular,  and  this  is  usually  accom- 
panied by  inflammation,  which  is  followed  by  more  or  less 
deformity  according  to  the  severity  of  the  inflammation. 

SIGNS. 

The  passages  having  been  thoroughly  cleansed,  direct  and 
indirect  rhinoscopic  inspection  with  a  strong  light,  together 
with  palpation  by  means  of  the  finger  or  a  probe,  will  usually 
detect  the  foreign  substance. 

*  See  treatment  of  chronic  coryza,  page  400. 


NASAL   TUMORS. 

409 

TREATMENT. 

The  offending-  substance  may  sometimes  be  removed  by 
means  of  the  posterior  nasal  douche,  by  curved  bougies,  or  by 
catheters  passed  into  the  nostril  from  behind.  Forceps,  a  hook 
or  wire  loop,  or  Gross'  instruments  for  removing  foreign  bodies 
from  the  nasal  passages  and  ears  (Fig.  135)  may  be  employed 
for  the  same  purpose. 


FIG.  135.— Gross'  instruments  for  removing  foreign  bodies  from  the  nasal  cavities 

and  ears. 


NASAL  TUMORS. 

A  great  variety  of  morbid  growths  have  been  found  in  the 
nasal  passages,  the  majority  of  which  spring  from  the  mucous 
membrane. 

The  different  varieties  occur  in  the  following  order  of  fre- 
quency :  first,  myxomata  or  mucous  polypi ;  second,  fibromata 
which  are  comparatively  infrequent ;  third,  adenomata ;  fourth, 
papillomata;  fifth,  neuromata ;  sixth,  enchondromata  and  osteo- 
mata.  These  latter  are  all  very  rare. 

SYMPTOMS. 

The  patient  experiences  a  sensation  of  fulness  in  the  nasal 
passages,  which  is  usually  increased  in  damp  weather.  Nasal 
respiration  is  obstructed,  and  the  voice  has  a  nasal  twang. 
Coryza  and  epistaxis  frequently  accompany  the  above  symp- 
toms. Deformity  results  if  the  growth  is  large.  The  sense  of 
smell  is  often  impaired  or  lost,  and  with  it  so  much  of  the  sense 
of  taste  as  depends  on  the  olfactory  nerves.  Hearing  is  im- 
paired when  the  orifice  of  either  Eustachian  tube  is  obstructed. 
There  may  be  difficulty  in  swallowing  if  the  tumor  presses 
upon  the  palate. 

•  SIGNS. 

Inspection  usually  reveals  the  existence  of  a  morbid  growth. 

Mucous  polypi  vary  greatly  in  size  and  in  number.     They  are 

occasionally  single,  but  usually  multiple.     They  are  generally 

attached  by  a  small  pedicle.     They  are  found  most  frequently 


THE   THROAT   AND   NASAL   CAVITIES. 

attached  to  the  upper  turbinated  bone,  though  they  may  spring 
from  the  middle  or  lower  turbinated  bones,  or  from  the  sep- 
tum. These  tumors  have  a  yellowish-white  color,  and  a  semi- 
transparent  appearance  ;  they  are  soft  to  the  touch,  owing  to 
their  serni-fluid  or  gelatinous  contents.  Exceptionally  they 
become  incrusted  with  calcareous  deposits  from  the  secre- 
tions. 

Fibrous  tumors  have  a  more  irregular  surface,  and  are  redder 
than  those  just  mentioned.  They  are  firm  to  the  touch  and 
bleed  easily.  These  growths  are  usually  single  and  sessile, 
though  they  are  occasionally  multiple  and  pedunculated. 
They  grow  gradually,  expanding  in  every  direction,  sending 
prolongations  into  adjoining  cavities,  and  causing  absorption 
of  surrounding  structures  by  pressure.  By  extension  into  the 
sinuses  they  may  cause  the  characteristic  deformity  known  as 
*'  Frog  face." 

The  adenoid  growths  may  attain  a  great  size.  They  present 
no  characteristic  appearance,  but  are  so  rare  that  they  are  not 
likely  to  be  mistaken  for  other  growths. 

Papillary  growths  usually  occur  near  the  nostril  and  are 
•easily  recognized. 

Neuromata  are  very  rare  in  the  nasal  passages. 

Cartilaginous  growths  spring  from  the  septum.  They  are 
•covered  by  mucous  membrane  which  may  have  a  normal  or 
congested  appearance. 

Osteomata  are  at  first  covered  by  mucous  membrane,  but 
later  this  gives  way,  and  the  bony  tissue  is  exposed.  The 
surface  of  these  growths  may  be  uniform  or  nodulated.  They 
attain  a  large  size  and  produce  great  deformity. 


DIAGNOSIS. 

The  diagnosis  must  be  made  by  inspection  and  palpation 
anteriorly  or  posteriorly,  or  in  both  directions. 

TREATMENT. 

We  should  remove  the  growth  through  the  natural  passages, 
•or  when  necessary  through  external  incisions.  Astringent  or 
caustic  injections  will  occasionally  cure  mucous  polypi,  but 
the  treatment  is  tedious  and  usually  unsatisfactory  ;  gener- 
ally it  is  best  to  remove  them  with  forceps.  Osteomata,  if 


NEUROSES  OF  THE   NASAL   PASSAGES.  4, , 

operated  o«  early,  can  usually  be  enucleated.  If  they  are 
friable,  they  may  be  crushed;  if  so  hard  as  to  prevent 
crushing,  they  may  be  reduced  by  the  dental  burr  or  drill,  as 
recommended  by  Dr.  Cohen.  Cutting  or  crushing  forceps,  the 
e"craseur,  the  galvano-cautery,  and  the  gouge  and  chisel  are  all 
useful  at  times  in  removing  these  growths. 


NEUROSES   OF  THE  NASAL  PASSAGES. 
ANOSMIA. 

Anosmia  or  loss  of  smell  is  sometimes  caused  by  blows  on 
the  head ;  but  it  is  often  due  to  inflammatory  affections  of  the 
nasal  mucous  membranes,  or  to  nasal  tumors,  or  other  causes 
of  obstructed  nasal  respiration. 

DIAGNOSIS. 
The  diagnosis  is  made  by  the  patient. 

TREATMENT. 

The  cause  for  this  symptom  must  be  sought,  and  if  found  in 
any  physical  alteration  of  the  nasal  cavities,  this  should  receive 
proper  treatment,  such  as  just  recommended  in  speaking  of 
the  various  conditions  which  cause  obstruction  of  these  pas- 
sages. Galvanization  of  the  mucous  membrane  with  a  weak 
current  should  be  tried  in  other  cases.  Generally  treatment 
will  be  ineffectual. 

» 

HYPER^STHESIA. 

Hyperaesthesia  is  characterized  by  frequent  sneezing  or  con. 
stant  snuffling.  Sneezing  may  be  excited  by  trifling  causes, 
and  may  be  prolonged  for  several  hours. 

TREATMENT. 

If  the  hypersesthesia  is  due  to  neuralgia  or  hysteria,  internal 
treatment  suitable  for  these  affections  is  indicated.     Locally.- 
Sedative  unguents,  or  sprays  containing  stramonium,  camphor, 
carbolic  acid,  and  the  like,  are  indicated. 


THE    THROAT   AND   NASAL   CAVITIES. 


PARALYSIS   OF   THE   NOSTRILS. 

This  may  be  entirely  local,  or  it  may  be  part  of  a  more 
general  paralysis. 

DIAGNOSIS. 

The  affection  will  be  recognized  by  the  flaccid  condition  of 
the  nostrils,  which  collapse  with  inspiration,  and  thus  obstruct 
nasal  breathing. 

TREATMENT. 

The  nostrils  may,  if  necessary,  be  kept  open  by  mechanical 
means.  This  is  sometimes  necessary,  in  order  to  relieve  the 
inflammation  of  the  throat,  which  is  likely  to  result  from  the 
patient's  having  to  breathe  constantly  through  the  mouth. 
The  ordinary  treatment  for  paralysis  should  also  be  employed. 


APPENDIX. 


v 


In  the  following  list  of  formulae,  those  which  relate  to  dis- 
eases of  the  throat  and  nasal  passages  are  mostly  taken  from 
the  Pharmacopoeia  of  the  Hospital  for  Diseases  of  the  Throat, 
London.  The  various  mixtures,  excepting  formula  4,  which 
would  never  be  prescribed  in-  quantities  of  less  than  four 
ounces,  have  been  reduced  to  the  standard  of  one  ounce. 
Some  of  these  I  have  found  very  beneficial  in  my  own  practice, 
and  others  have  been  inserted  on  the  recommendation  of 
various  distinguished  physicians. 

1.  #  Tinct.  aconiti  radicis ^  viij. 

Aquae fl-   2  '• 

M.  S.  Teaspoonful  at  a  dose.  Repeat  every  half-hour  or 
hour,  at  first,  and  subsequently  less  frequently  in  acute  inflam- 
matory affections  of  the  air  passages. 

2.  $  Morphise  sulphatis ST-  \ 

Antimonii  et  potass,  tart gr- 

Ammonii  chloridi 

Ext.  grindeliae  robustae  fluidi fl- 

Syrupi  pruni  virginianae  et 

Misturae  glycyrrhizse  comp M  fl 

M.  *S.  Teaspoonful  for  cough.  Especially  useful  in  acute 
bronchitis. 

3.  t£  Morp'hise  sulphatis 8r_  »• 

Chloral •'*£ 

Syrupi  zingibens ' ' '    ,  ' 

Misturse  glycyrrhizae  comp 

M.     S.  Teaspoonful  every  half-hour  or  hour  until 
For  spasmodic  asthma. 


414  APPENDIX. 

i 

Emulsion  of  Cod-Liver  Oil. 

4.  IJ  Olei  morrhuae 3  xvi. 

Sach.  alb.  (granulated) 3  vi. 

Acaciae 3  iv. 

Olei  gaultheriae TIJ,  xv. 

Aquae q.  s.  ad  fl.  §  iv. 

Triturate  the  sugar  and  acacia  thoroughly  with  one  half  the 
amount  of  water,  until  a  uniform  mucilage  is  formed  ;  then  add 
the  oil  slowly,  with  constant  trituration,  and  subsequently  add 
the  remainder  of  the  water.  (It  requires  about  an  hour  to 
make  the  emulsion  properly.) 

This  makes  a  very  perfect  emulsion,  to  which  may  be  added 
lactophosphate  of  calcium  or  phosphoric  acid,  which  will  give 
it  an  agreeable  acidulous  taste.  Chloride  of  calcium  may  be 
added  when  desired,  but  the  lactophosphate  of  calcium  will 
doubtless  answer  the  same  remedial  purpose. 

5.  IJ  Morphias  sulphatis gr.  i. 

Ammonii  carbonatis gr.  xxx.-xl. 

Syr.  pruni  virg., 

Misturae  glycyrrhizae  comp aa  fl.  3  iv. 

M.     S.  Teaspoonful,  in  water,  for  cough. 

6.  IJ  Antimonii  et  potassii  tartratis gr.  xx. 

Cantharidis  et 

Olei  tiglii ail  gr.  xl. 

Camphorae  et 

Ext.  stramonii  (aq.) fui  gr.  Ixxx. 

Adipis 3  iiss. 

Cerati  simplicis ad  3  i. 

M.     S.  Counter-irritant  ointment. 

7.  Ijl  Tincturae  iodinii 3  ss.-  3  i. 

Potassii  iodidi gr.  x.-x*x. 

Aquae ad  fl.  3  i. 

M.  S.  Use  as  an  injection,  which  should  be  withdrawn  in 
about  five  minutes.  For  chronic  pleurisy. 

8.  IJ,  Ext.  euonymi  fluidi fl.  §  i. 

S.  One  teaspoonful  to  be  taken  four  or  five  times  a  day  with 
water. 
A  valuable  diuretic  and  cathartic  in  cardiac  disease. 


APPENDIX.  ,  4,j 

In  place  of  the  above,  an  infusion  made  with  one  ounce  of 
the  plant  to  a  pint  of  water  may  be  used  in  doses  of  a  wine- 
glassful. 

GARGLES. 

Gargles  are  only  useful  in  diseases  of  the  fauces.  They  can- 
not affect  the  nasal  passages,  pharynx,  or  larynx.  These  prep- 
arations may  be  'sedative,  astringent,  stimulant,  or  antiseptic. 

Sedatives. 

9.  1^  Potassii  broraidi gr.  x.  ad  ft.  -"  i. 

TO.  "    Potassii  nitratis gr.  xx. 

Potassii  chloratis gr.  x. 

Aquae  ferv ad  fl.  3  i. 

M.     S.  Use  as  hot  as  it  can  be  borne. 

11.  fy  Acidi  carbolici gr-  i-  <*d  A.  :   i. 

Astringents. 

12.  ^  Acidi  tannici gr.  xij.-  3  ii.  ad  fl.  ;  i. 

13.  "    Aluminis gr.  viij.  ad  fl.  §  i. 

14.  "    Ferri  et  ammonii  sulphatis gr.  viij.  ad  fl.  1  i. 

15.  fy  Sodii  biboratis gr.  xxv. 

Glycerinae   ^  XXVg 

Tinct.  myrrhae ^  xxv- 

Aquae ad  * 

M. 

Stimulants. 

16.  1£  Acidi  acetici  dil ^ 

Glycerinae "^fll'i' 

Aquae 

M. 

17.3  Acidi  carbolici gr- 1J- 

,8.  "    Potassii  chloratis gr.  x.-xxv.  a^  fl 

Antiseptics. 


19.  IJ  Acidi  carbolici  vel 

Potassii  chloratis,  (see  stimulants). 

.•  er   i  -ii.  ad  fl-  "  '• 

20.  #  Potassii  permanganatis 


4l6  >  APPENDIX. 


TROCHISCI,   OR   LOZENGES. 

Each  lozenge  contains  seventy  to  eighty  per  cent  of  red 
currant  fruit  paste,  one  to  two  per  cent  of  powdered  traga- 
canth,  four  per  cent  of  sugar,  and  a  varying  quantity  of  the 
medicament,  according  to  the  following  formulae. 

Sedatives. 

2 1.  $  Morphiae  sulphatis gr.  ^  ad  troch. 

22.  "    Ext.  opii gr-  iV  "       " 

.23.  "    Sodii  biboratis gr.  iij.  "       " 

24.  "    Ammonii  chloridi ....    gr.  ij.  "       " 

Astringents. 

25.  ^  Kramerise gr.  iij.  ad  troch. 

26.  "    Kino gr.  ij.  "       " 

27.  "   Acidi  tannici gr.  iss.  "       " 

Stimulants. 

28.  5  Acidi  benzoici   . .    gr.  ss.  ad  troch. 

29."   Cubebse .gr.  ss.  "       " 

30.  "    Guaiaci gr.  ij.-iij.  "       " 

31.  "    Pyrethri gr.  i.  "       " 

Potassium  chlorate  is  more  pleasant  and  more  efficacious  in 

compressed  pills  than  in  troches. 

A  ntiseptics. 

32.  5.  Acidi  carbolici gr.  i.  ad  troch. 

Potass,  chloratis,  (see  stimulants). 

VAPOR   INHALATIONS. 

These  may  be  used  with  various  forms  of  inhalers.  Mac- 
kenzie's eclectic  inhaler  is  the  most  complete,  but  some  of  the 
cheaper  instruments  will  answer  the  same  purpose.  The  best 
of  the  cheap  inhalers  was  devised  by  the  late  Dr.  F.  H.  Davis, 
of  this  city.  An  inhaler  which  is  in  common  use  consists  of  a 
glass  flask  holding  about  a  quart.  This  has  a  perforated  cork, 
through  which  two  glass  tubes  are  passed,  one  to  the  bottom 


APPENDIX. 

of  the  flask  to  admit  the  air,  and  the  other,  through  which  the 
patient  inhales  the  vapor,  into  its  upper  part.  Almost  any  of 
the  numerous  inhalers  may  be  used  for  the  purpose,  or  in  the 
absence  of  an  inhaler  an  earthen  teapot  may  be  employed. 
These  inhalations  are  prepared  by  adding  a  teaspoonful  of  the 
medicated  solution  to  a  pint  of  water,  at  a  temperature  of  about 
150°  F.  They  should  be  used  morning  and  evening  for  about 
five  minutes  each  time,  six  respirations  being  taken  per 
minute. 

The  oleaginous  or  balsamic  remedies  should  be  rubbed  up 
with  light  carbonate  of  magnesium,  in  order  to  maintain  their 
suspension  in  the  water,  as  shown  in  the  following  formula. 

33.  3  Olei  cajuputi  .................................  ^  viij. 

Mag.  carb.  lev  .................................  gr.  v. 

Aquae  ......................................  *<?  fl-  3  i- 

M.  S.  A  teaspoonful  in  a  pint  of  water  at  150°  F.,  for  each 
inhalation. 

These  vapors  maybe  sedative,  antispasmodic,  antiseptic,  or 
gently  or  strongly  stimulant. 

Sedative  Vapors. 

34.  3  /Etheris  et  spts.  vini  reel  ..........................  1UI- 

35.  "   Chloroformi  et  spts.  vini  rect  ......................  a;l- 

36.  "    Lupulinae  .....................  ..............  gr.  xxx. 

37.  "   Aqueous  ext.  belladonnae 

vel  ext.  stramonii  ........................  gr.  v.  a//  :  i. 

38.  "    Aqueous  ext.  opii  ........................  gr.  v.  «</ 

39.  "   Tinct.  benzoin,  comp  ...........................  fl-  3  J' 

40.  "   Tinct.  opii  camph  .............................  fl- 

A  ntispasmodics. 

41.  3  yEtheris  vel  chloroformi  (as  above). 


42.        Amyl  nitrite  .........................  . 

Mild  Stimulants. 
43.3  Olei  pini  sylvestris  .....................  m  xl.  a^  fl.  =  i- 

44.  "    Oleicubeb*  ...........................  3 

45.  •«    Olei  cassia  .......................  ^.V.V 

Olei  limoms  ................. 

M. 

27 


41 8  APPENDIX. 

46.  $  Oleianisi m  vi.  ad  fl.  1  i. 

47.  "   Tinct.  benzoin,  comp fl.  3  i. 

48.  "    Olei  myrti TU  vi. 

Camphorse gr.  v.  ad  fl.  §  i. 

M. 

More  stimulating  than  the  above. 

49.  3  Acidi  carbolici gr.  xx.  ad  fl.  3  i. 

50.  "   Creasoti Til  xl.  «</  fl.  §  i. 

51.  "   Olei  cari TTJ,  vi.  #</  fl.  3  i. 

52.  "   Olei  juniperi TTj,  xx.  ad  fl.  3  i. 

Strong  Stimulants. 

53.  $  Olei  calami  arom TTl  v.  #</  fl.  3*  i. 

54.  "    Olei  caryophylli . . . .  ..1TJ,  x.  <ft/fl.  §  i. 

55.  "    Tinct.  iodinii  comp TT],  x. 

S.  Repeat  two  or  three  times  at  each  inhalation. 

56.  $  Aquae  ammonias  et  aquae aa  fl.  3  iv. 

Antiseptics. 

57.  $  Acidi  carbolici,  creasoti 

vel  olei  juniperi  (as  in  49,  50,  and  52). 

58.  "    Potassii  permanganatis gr.  v.  ad  fl.  §  i. 

SPRAY   INHALATIONS. 

These  are  to  be  used  by  the  patient  in  full  strength,  with 
the  hand-ball  atomizer,  or  in  about  twice  this  strength  by  the 
steam  atomizer.  One  or  two  drachms  should  be  used  at  each 
inhalation.  These  applications  are  useful  principally  in  treat- 
ing diseases  of  the  fauces  and  of  the  nasal  cavities.  It  is  almost 
impossible  for  the  patient  to  draw  them  into  the  larynx.  These 
inhalations  may  be  classified  as  sedatives,  astringents  or  stim- 
ulants, haemostatics,  and  antiseptics. 

Sedatives. 

59.  $  Acidi  hydrocyanici  dil 3  ss.  ad  fl.  §  i. 

To  be  used  only  as  a  cold  spray. 

60.  IJ  Potassii  bromidi gr.  x.  ad  fl.  §  i. 


APPENDIX. 

419 

Astringents  and  Stimulants. 
6r.  ft  Aciditannici gr.  iij.  W  fl.  =  j. 

62.  '•    Zinci  sulphatis gr.  ij.-x.  itffl.  3  i. 

63.  "    Zincichloridi gr.  ij.-x.  «/ fl.  3  i. 

64.  "    Aluminis gr.  x.  */ fl.  3  i. 

65.  "    Ferri  perchloridi gr.  iij.  *</fl.  f  j. 

H<zmostatics. 

66.  3  Ferri  perchloridi.. gr.  v.  ^fl.  §i. 

67.  "    Aciditannici gr.  x.  a,/ fl.  =  i. 

Antiseptics. 

68.  5,  Sodii  benzoatis 3  i.  «</  fl.  :  i 

69.  "    Aquae  calcis fl  zj 

70.  "    Brominii gr.  ss.  Wfl.  §i. 

71.  "    Potassii  bromidi gr.  Xxv.  ad  fl.  3  i. 

72.  "    Acidi  lactici  medicinalis TTl  Xx.  ad  fl.  3  i. 

73.  "    Potassii  permanganatis gr.  v.  ar/ fl.  §  i. 

74.  "    Potassii  chloratis. .    gr.  xx.  ad  fl.  3  i. 

DRY   INHALATIONS. 

These  are  composed  of  substances  which  volatilize  at  ordi- 
nary temperatures,  or  simply  by  the  heat  of  the  hand.  They 
may  be  used  with  any  of  the  instruments  which  are  ordinarily 
used  for  vapor  inhalations,  or  they  may  be  easily  inhaled 
from  a  small  wide-mouthed  bottle,  in  the  bottom  of  which  the 
medicine  has  been  placed. 

One  of  the  simplest  and  most  efficacious  inhalers  for  this 
purpose  consists  of  a  glass  tube  about  four  or  five  inches  in 
length,  open  at  both  ends,  and  holding  a  small  sponge  at  its 
middle.  The  remedy  is  dropped  on  the  sponge,  and  air  is 
inspired  through  the  tube. 

When  these  substances  are  used  with  the  small  glass-tube 
inhaler,  the  amount  given  for  each  inhalation  should  be  divided 
into  three  or  four  parts  which  are  to  be  used  successively. 

If  the  effect  is  only  needed  in  the  throat  and  nose,  the  solu- 
tion may  be  concentrated  so  that  the  same  amount  of  medicine 
will  be  obtained  without  repeatedly  charging  the  inhaler.  In 


420  APPENDIX. 

this  case,  the  patient  should  not  inspire  deeply,  and  only  two 
or  three  inhalations  should  be  taken  per  minute.  These  inha- 
lations may  be  sedative  or  stimulant. 

Sedatives  and  Antispasmodics. 

75.  I£  Acidi  hydrocyanic!  diluti fl.  3  i.  ad  fl.  3  i. 

S.  A  teaspoonful  at  each  inhalation. 

76.  3  ^theris.     S.  A  half  teaspoonful  at  each  inhalation. 

77.  "    Amyl  nitrite "HI  i. 

Alcohol TT[  xxx. 

M.  S.  Use  at  each  inhalation.  This  is  useful,  especially  in 
spasmodic  affections. 

78.  $  Olei  santili  albi TTI  i. 

Alcohol ad  fl.  3  i. 

M.     S.  To  be  used  at  each  inhalation  in  divided  doses. 

79.  1J  Chloroformi fl.  3  ss. 

S.  To  be  used  at  each  inhalation ;  to  be  breathed  slowly. 

Stimulants. 

80.  1J  Tinct.  iodinii T1J,  x.-xx. 

In  this  same  category  may  be  included  the  carbonate  of 
ammonium  and  camphor  used  as  smelling  salts ;  and  nascent 
chloride  of  ammonium  used  by  any  of  the  inhalers  constructed 
especially  for  that  purpose. 

FUMING   INHALATIONS. 

Fuming  inhalations  are  prepared  by  saturating  bibulous 
paper  with  a  solution  of  the  remedy  of  a  given  strength,  dry- 
ing the  paper,  and  then  cutting  it  into  twenty  equal  parts, 
each  of  which  will  contain  one  twentieth  of  the  amount  of 
medicine  used.  These  strips  may  be  rolled  into  cigarettes,  or 
they  may  be  burned  under  a  funnel  which  will  conduct  the 
smoke  to  the  mouth.  They  are  employed  in  asthma  and  spasm 
of  the  larynx.  The  principal  medicines  employed  in  this 
manner  are : 

81.  Potassii  arsenias gr.  xv., 

82.  Sodii  arsenias. gr.  xx.-xl.  or 


APPENDIX. 

42 1 

83.  Potassii  nitras gr.  xxx._Jx<| 

AclU8e adfal'i. 

These  latter  may  be  modified,  as  recommended  in  the  Throat 
Hospital  Pharmacopeia,  by  the  addition  of  various  volatile 
principles. 

These  volatile  substances  are  added  by  moistening  the  nitre 
paper  in  a  tincture,  or,  in  the  case  of  volatile  oils,  in  a  solution 
of  one  part  of  the  oil  to  nine  parts  of  alcohol,  and  then  expos- 
ing the  paper  to  the  air  a  few  minutes  to  allow  the  alcohol  to 
evaporate.  These  papers  must  be  freshly  prepared  and  kept 
in  tinfoil.  The  following  are  the  preparations  most  useful : 

Sedatives. 

84.  Nitrated  papers  with  tinct.  benzoini  comp. 

85.  Nitrated  papers  with  tinct.  hyoscyami  vel  stramonii. 

86.  Nitrated  papers  with  oil  of  sandal. 

87.  Nitrated  papers  with  oil  of  sumbul. 

Stimulants. 

88.  Nitrated  papers  with  spirits  of  camphor. 

89.  Nitrated  papers  with  oil  of  cinnamon. 

90.  Nitrated  papers  with  oil  of  cassia. 


PIGMENTS. 

This  name  is  given  to  the  various  mixtures  which  are 
designed  for  topical  application  by  means  of  a  brush.  These 
may  be  prepared  with  water  or  with  glycerine,  but  it  should 
be  remembered  that  the  latter  is  irritating  to  some  throats. 
These  pigments  may  be  anaesthetic,  astringent,  stimulant,  or 
antiseptic  in  their  effects. 

Local  Anesthetics. 

91.  I£  Morphise  sulphatis gr- 1V- 

Acidi  carbolici 8r-  x?* 

Glycerins fl'  *  u 

M. 

Thirty  grains  of  tannin  may  be  added  to  the  above  when  a 
slightly  astringent  effect  is  desired. 


422 


APPENDIX. 


92.  $  Chloral  .........................................  3  i. 

Aquae  ......................  ................  ad  fi.  3  i. 

93.  IJ  Morphias  sulphatis  ............................  gr.  xx. 

Chloroformi  ................................  a  d  fl  .  §  i. 

Astringents. 
94   IJ  Zinci  chloridi  .........................  gr.  x.  ad  fl.  3  i. 

95.  "   Zinci  sulphatis  ....................  gr.  x.-xxx.  ad  fl.  f  i. 

96.  "    Ferri  et  ammonii  sulphatis  ............  gr.  xxx.  ad  fl.  §  i. 

97.  "    Liquor  ferri  perichloridi  ................  ffl  xl.  ad  fl.  3  i. 

98.  "    Acidi  tannici  ...................................  3  ij. 

Glycerinse  ...................................  ad  fl.  f  i. 

Stimulants  and  Caustics. 

99.  IJ  Zinci  chloridi  .......................  gr.  xxx.  ad  fl.  3  i. 

100.  "  Cupri  sulphatis  .......................  gr.  xx.  ad  fl.  3  i. 

101.  "  Liq.  ferri  perchloridi  ..................  fl.  3  ij.  ad  fl.  3  i. 

102.  "  Argenti  nitratis  ....................  3  ss.-  3  i.  ad  fl.  3  i. 

103.  "  Liquor  hydrargyri  nitratis  .........  Til,  xl.-  3  ij.  fl.  ad  3  i. 

104.  "  Tinct.  iodinii  ........................  .  .........  3  i. 

105.  "  Iodinii  .....................................  gr.  xxx. 

Glycerins  ...........................  .  ......  ad  fl.  3  i. 

A  ntiseptics. 

106.  IJ  Acidi  carbolici  ............  .  .....  .....  gr.  xxx.  od  fl  3  i. 

INSUFFLATIONS. 

Powders  have  been  extensively  used  in  the  treatment  of 
nasal  and  laryngeal  affections,  but,  with  Lennox  Browne,  I  think 
them  useful  in  only  a  few  cases.  I  am  accustomed  to  dilute  all 
of  the  powders  which  I  employ  with  from  one  to  four  parts  of 
sugar  of  milk,  acacia,  or  starch.  The  following-  formulas  each 
represent  the  amount  of  the  medicine  itself  which  is  to  be 
used  at  each  insufflation. 

107.  5  Acidi  tannici  ............................  gr.  ss.-gr.  ij. 

108.  "  Bismuthi  carbonatis  .......................  gr.  i.-gr.  ij. 

109.  "  Bismuthi  subnit  ...........................  gr.  i.-gr.  ij. 

1  10.  "  Hydrastine   ..............................  gr. 


APPENDIX.  „,-. 

423 

1  1  1  .  I£  lodoformi  .....................................  gr,  i. 

112.  "  lodoformi  .....................................  gr.  i. 

Bismuthi  carb  .................................  gr.  jj. 

M. 


113.5  Morphiae  sulphatis  ........    ..............  gr. 

Bismuthi  carb  .................................  gr.  ij. 

M.     Or  the  above  with  the  addition  of  tannin  or  iodoform. 

Nasal  Douches. 

The  following  preparations  may  be  used  either  by  the  ante- 
rior or  posterior  nasal  douche,  for  detergent  or  antiseptic 
purposes.  They  should  be  followed  by  more  potent  remedies. 
The  amount  given  below  should  be  added  to  ten  ounces  of 
water  at  blood-heat,  and  part  or  all  of  it  used  at  each  applica- 
tion. 

1  14.  3  Sodii  chloridi  ...............................  gr.  3  i. 

115.  "  Sodii  bicarbonatis  ..............................  3  ij. 

116.  "  Potassii  permanganatis  ........................  gr.  ij. 

117.  u  Acidi  carbolici  ................................  gr.  xx. 

1  18.  "  Zinci  sulphocarbolatis  ........................  gr.  xx. 


INDEX. 


Abscess  infra-glottic,  illustration,  347 
nasal,  406 
of.  heart,  229 

of  larynx,  347;  diffused,  344 
retro-pharyngeal,  324 
Accentuation  of  heart-sounds,  184 
Aconite  in  bronchitis,  105;  in  pneumonia, 

126 

Adams'  electric  laryngoscope,  271 
Adenoma  at  vault  of  pharynx,  403 
Adenomata  of  larynx,  371 
Adventitious  pulmonary  sounds,  65 
yEgophony,  sign  of  pleuro-pneumonia,  76; 
in   ordinary  pleuritic   effu- 
sions, 77 

Age,  effects  of,  on  vesicular  murmur,  54 
Alcohol  in  phthisis,  155 
Allison,  23,  50 

Allison's  differential  stethoscope,  186 
Ammonium   salts   in  bronchitis,   105;   in 

pneumonia,  126 
Amphoric  cough,  80 
echo,  77 

respiration,  causes,  63 
respiration    in    pneumothorax, 
99;    resonance   and   diseases 
causing   it,    41;   in  pleurisy, 
83;  in  pneumothorax,  99;  oc- 
casionally in  pneumonia,  122 
voice,'  77;  'in    pneumothorax 

and  phthisis,  78 
whisper,  78 
Amygdaliiis,  306,  32j 
Anremia,  effects  on  vesicular  murmur,  54 
Anaesthesia  of  larynx,  383 

of  pharynx,  325 
Anchylosis  of  arytenoid  cartilages,  395 


Aneurism  of  aorta,  240;  marbled  appear- 
ance of  the  chest,  oedema, 
and  turgescence,  242;  sphyg- 
mographic  tracings,  illustra- 
tion, 208 

of  the  arteria  innominata,  246 
of  the  descending  aorta,  249. 
of  the  heart,  219,  229 
of  the  pulmonary  artery,  246* 
of  the  sinuses  of  Valsalva,  239, 
Aneurisms,  treatment  of,  250 
Angina  erythematosa,  305;    epiglottidea,. 
laryngea,  330;   laryngea   infil- 
trata,  348;  membranacea,  308; 
phlegmonosa,   tonsil laris,  306; 
trachealis,  341 
Anosmia,  411 
Anstie,  211 

Aorta,  162,  165;  aneurism  of,  240;  athe- 
roma  of,  237;  pulsation  of,  175 
descending,  aneurism  of,  249 
coarctation  of,  250 
Aortic  endarteritis,  237 

murmur,    diastolic,    198;    systolic,. 

197 

murmurs,  area  of,  194 
obstructive  murmurs,  200;   sphyg.- 

mographic  tracings,  208 
pulsation,  248 
regurgitant  murmurs,  201;  sphyg*. 

mographic  tracings,  209 
Aortitis,  237 
Apex  beat  of   heart,   172;    displacement 

of,  99.  173 

Aphonia,  functional,  389 
A  phonic  pectoriloquy,  79 
Aphthous  sore  throat,  308, 


426 


INDEX. 


Apneumatosis,  135 
Appendix,  various  formulae,  413 
Area  of  cardiac  impulse,  173 
Areas  of  cardiac  murmurs,  191,  illustra- 
tion, 192 
Arnold,  363 
Arsenic   in   asthma,    114;    in  bronchitis, 

106;  in  emphysema,  119 
Arteria  innominata,  aneurism  of,  246 
Arterial   pulsation   as   a   sign  of  cardiac 

disease,  171 
Ary-epiglottic  or  aryteno-epiglottic  folds, 

295 

Arytenoid  cartilages,  294 
Asthma,  113;  rales  in,  66 
Aspiration  in  pleurisy,  88 
Asystolism,  223 
Atelectasis,  135 
Atheroma  of  aorta,  237 
Atomizer,  illustrations,  401 
Atrophy  of  the  heart,  225 

of  the  vocal  cords,  396 
Auricle,  .dilated,  differentiated   from   an- 
eurism, 248 

pulsation  of,  differentiated  from 
pulsation  due  to  aneurism  of 
the  aorta,  173 

Auscultation,  mediate  and  immediate,  46; 
rules  for,  51;   in  health, 
52;    in    disease,    56;    in 
examination  of  heart.  181 
.Auscultatory  percussion,  44;  in  examina- 
tion of  heart,  181 
sounds,  elements  of,  52 
Autumnal  catarrh,  397 
Avenbrugger,  28 
Avery,  256 

«8*i 

Babbington,  256 
Balfour,  195,  235 
Barrel-shaped  chest,  15 
Baumes,  256 

Belladonna   in   asthma,    114;    for   night- 
sweats,  155 
Belloc's  canula,  256 
Bell-sound,  42;  in  pneumothorax,  99 
Bennatti,  256 
Bird,  1 60 
Bizot,  237 


Boileau,  209 

Bos  worth,  402 

Boyle,  141,  147 

Bozzini,  256 

Breathing,  superior  costal,  inferior  costal, 

and  abdominal,  10 

Bright's  disease,  cause  of  pneumonia,  131 
Bronchi,  main,  illustration,  299 
Bronchial  breathing  in  pneumothorax,  99 
cough,  79 

glands,  enlarged,  144 
hemorrhage  distinguished  from 

bronchitis,  105 
respiration,  53,  61,  155 
whisper  exaggerated,  78 
Bronchiectasis,    111;    differentiated    from 
pulmonary     gangrene, 
140 
Bronchitis,  acute,  102 

capillary,  106 
chronic,  104 

differentiated    from   pneumo- 
nia, 125;    from  pulmonary 
gangrene,  140 
plastic,  109 
rales  in,  66,  68 

Broncho-cavernous  respiration,  cause,  62 
vesicular  respiration,  to 
pneumonia,  127 

Bronchophony,  normal,  74;  in  pneumonia 
and   phthisis,    76;    sel- 
dom obtained  in  phthi- 
sis, 76 
Brown  induration  of  lung,  157;  rales  in, 

68 

Browne,  314 

Brans'  pincette,  illust  ation,  284 
Bursa  pharyngeus,  304 

Calcium   chloride  in   bronchitis,   112; 

phthisis,  155 
Calculi  in  tonsil,  323 
Calomel  in  croup,  344 
Camman,  44,  48,  50 
Cancer  of  larynx,  372;  illustrations,  373; 

differentiated     from     syphilitic 

laryngitis,  361 
of  lung,   141;   differentiated  from 

pleurisy,  93 


INDEX. 


427 


Capillary  bronchitis,    106;   differentiated 

from  asthma,  114 
Carcinoma  of  larynx  differentiated  from 

benign  tumors,  372 
Cardiac  auscultation,  rules  for,  181 
diseases,  212 

dulness.  superficial  and  deep,  179 

murmurs,    aortic,  197,   198,  200; 

causes,   195;  illustrations,   196; 

haemic,  202;  mitral,  195,   196, 

200;     organic    and    inorganic, 

189;  pulmonary,  197,  198,  201; 

quality,    195;    tricuspid.    195, 

197,    201 ;    seat,    rhythm,    and 

.  quality,   190;   ventricular,   199, 

201 

pulsation,  166 
Carroll   22 

Cartilages,  arytenoid,  of  Sartorini  and  of 

Wrisberg,  295;  cricold.298; 

supra-arytenoid,    295;    tra 

cheal,  298 

Catarrh   of   larynx,  acute,   330;   chronic, 

335 

nasal.  398 
Catarrhal  pneumonia,  135 

tonsillitis,  305 
Cavernous  whisper,  78 

respiration,  cause,  62;  illustra- 
tion, 63 

Cavities  in  lungs,  64 

Charriere's     amygdalotome,     illustration, 

Chaveau,  190  [323 

Chest,    circumference    of,    22;    deviation 

from  symmetry  in  the  healthy, 

10,  ii ;  form  and  movements  of 

in  disease,  16 

pear-shaped,  long,  narrow,  or 
flat,  id;  tranverse  outlines,  Ii; 
illustrations,  3,  4,  II 
walls,  falling  in  of,  in  emphysema, 
116;  -retraction  of  in  pleurisy, 
88 

Cheyne- Stokes  respiration,  226 
Chloral  in  asthma,  114 
Chondritis  and  perichondritis   of  the  la- 
ryngeal  cartilages,  352;  di- 
agnosis  and   treatment   of, 
353 


Circles  of  dispersion  in  illuminating  the 

larynx,  259 

Cirrhosis  of  the  lung,  in,  147,  152 
Clark,  44 
Clavicular    region,    percussion    signs    in 

health,  34 

Clergyman's  sore  throat,  311 
Climate  for  consumptives,  156 
Coarctation  of  aorta,  250 
Coffee  in  asthma,  114 
Cog-wheel  respiration.  83 
Cohen,  314.  367,  383,  407 
Collapse  of  the  lung  from  compression,  92 
Condylomata,  syphilitic,  of  larynx,  372 
Congestion,  pulmonary,  131 
Consumption,  147 
Corvisart.  230 

Coryza,  acute,  398;  chronic,  399 
Cough,  cavernous  and  amphoric,  80;  ir- 
ritative.   382;     laryngeal     and 
bronchial,  79;  spasmodic,  383 
Countenance  in  emphysema,  15 
Counter-irritation  in  pneumonia,  126;  in 

bronchitis,  106 
Cracked-pot  resonance,  42 
Crackling  sounds,  71,  72 
Crepitant  rale,  68;  not  developed  in  every 

case  of  pneumonia,  122 
Cricoid  cartilage,  298 
Croup,  341;  differentiated  from  acute  lar- 
yngitis. 332 

spasmodic  or  cerebral,  381 
Croupous  bronchitis,  109 
Crumpling  sounds,  72 
Curved  line  of  flatness  in  pleurisy,  84 
Cyanosis  or  the  blue  disease.  234 

in  pulmonary  and  cardiac  dis- 
eases. 12 

Cynanche  laryngea,  330 
pharyngea.  305 
tonsillaris,  320 
Cystic  growths  of  larynx,  371 
Cystometer,     illustrations    (Flint's     and 

Gee's),  23 
Czennak,  256,  263 

Da  Costa,  2,  86 
Damoiseau.  83 
Dan  forth,  371 


428 


INDEX. 


Decubitus  in  pleurisy,  13 
Diagnosis  of  pulmonary  diseases,  8 1 
Diaphragmatic  hernia  differentiated  from 

pneumothorax,  182 
Diastole  of  the  heart,  166 
Digitalis,  in  pneumonia,  126;  in  diseases 

of  the  heart,  233 
Dilatation  of  the  bronchial  tubes,  in 

of  the  heart,  222 

of    the  right  ventricle  in  em- 
physema, 117  [343 
Diphtheria,  319;  differentiated  from  croup, 
Diphtheritic  bronchitis,  109 

paralysis  of  fauces,  326 
Dobell's  solution,  402 
Dodge,  344 

Douche,  nasal,  illustrations,  400 
Dover's  powder  in  bronchitis,  105 
Dropsy,  in  cardiac  diseases,  12;  supra-  or 

infra-glottic,  348 
Dulness  on  percussion,  causes,  39 

in  pleurisy,  82 

Duration  of  percussion  sounds,  30 
Dysphagia  in  aneurism,  241 
Dysphonia  in  aneurism,  241 

Effusion,  quantity  of,  in  pleurisy,  81 
Effusions  into  the  pericardium  differenti- 
ated from  enlargement  of  the 
heart,  180 
Ellis,  83 

Emballometer,  Ingals',  illustration,  45 
Embolism,  pulmonary,  134 
Emphysema,  atrophous,   116;  subcutane- 
ous, 12 

pulmonary,  115;  differenti- 
ated from  bronchitis,  104; 
from  pneumothorax  and 
pneumo-hydrothorax,  100, 
IOI,  103 
Empyema,  90 

pulsating,  differentiated  from 

aneurism,  348 

Emulsion  of  cod  liver  oil,  414 
Endocardial  murmurs,  189 
Endocarditis,  217 

ulcerative,  231 

Epigastric   pulsation,    175,    176;    in   em- 
physema, 117 


Epiglottis,  various  forms  of,  illustrations, 
291,  293;  respiratory  move- 
ments, 292;  paralysis  of 
depressors  of,  386 

Ergot  in  pneumonia,  126 

Erysipelatous  laryngitis,  345 
sore  throat,  307 

Erythematous  sore  throat,  305 

Eustachian  tube,  orifice  of,  302 

Eversion  of  the  ventricles,  377 

Exaggerated  respiration,  causes,  56 
vocal  resonance,  75 

Expiration,  prolonged,  59;  in  emphysema, 

15,  «7 
Expiratory  sounds  in  the  infra-clavicular 

region  in  health,  54,  59 
Exudative  bronchitis,  109 

laryngo-tracheitis,  341 
Eye,  distance  from  glottis  in  laryngoscopy, 
275!  position  of,  in  laryngoscopy, 
259 

Fatty  degeneration  of  heart,  225 

diathesis,  225 

Fauces,  examination  of,  254;  healthy  ap- 
pearance    of,     256;     irritable, 
management  of,  282;  irritable, 
as    an    obstacle  to  rhinoscopy, 
288;  foreign  bodies  in,  324 
Fibro-cellular  tumors  of  larynx,  370 
Fibroid  disease  of  the  heart,  230 

phthisis,  147,  152 
Fibromata  of  larynx,  soft,  370 
Fibrosis  of  lung  differentiated  from  em- 
physema, 119 
Filer's  phthisis,  in 
Fissures,  pulmonary,  9 
Flatness,  diseases  causing  it,  40;  in  pleu- 
risy, 83 

Flint,  33,  62,  86,  140,  150 
Fluctuation  in  pleurisy,  21,  90 
Fluid,  surface  of,  in  pleurisy,  83 
Focal   distance  of   reflectors,  how  deter- 
mined, 263 
Follicular  glossitis,  acute,  311 

pharyngitis,  acute,  309;  chronic, 

3" 

tonsillitis,  321 
Forceps,  laryngeal,  illustrations,  375,  376 


INDEX. 


429 


Fossa  of  Rosenmueller,  303 
Foster,  207 

Fraenkel,  his  illuminator,  266;  his  rhino- 
scope,  illustration,  273 
Fraentzel,  86 
Frank,  273 

Fremitus,  rhonchial,  103;  fr'ction,  20,  176 
Friction     in     pericarditis,     91;     cardiac- 

pleural,  189 

sounds,    illustration,    71;    peri- 
cardial,  188 

Galvanism  in  asthma,  114 
Garcia,  256 
Gardner,  168 
Gargles;  415 
Garland,  84 
Gee,  23 

Glossitis,  acute  follicular,  311 
Glottis,    296;    distance    from    lips,    259; 
paralysis  of,  241,  295;  spasm 
of,  241 

Goitre,  aerial,  378 

Granulations,  fungous,  in  larynx.  372 
Grazing  friction  sounds,  71  [114 

Grindelia  robusta,  fluid  extract  in  asthma, 
Gross'  instruments  for  removing  foreign 

bodies  from  the  nasal  passages, 

illustration,  409 
Gueneau,  95 

Gummata,  syphilitic   in  larynx,    illustra- 
tions, 360 
Gureles.  illustration,  63,  70 


Hsemadynamometer, 


Hammond's,    illus- 
tration, 25,  26 
Hremic  murmurs,  2O2 
Hremopiysis  in  aneurism  of  aorta,  242 
Haemorrhage,  pulmonary,  133 
Hamilton,  344 
Hammer  pulse,  174 
Hammond,  26 
Harsh  respiration,  60 
Hay-asthma,  hay-fever,  397 
Hayden,  208 

Headache  in  aneurism  of  aorta,  241 
Head-bands  for  holding  reflector,  264 
Head,  position  of,  in  rhinoscopy,  illustra- 
tion, 286 


Healthy  chest,  aspect  of,  9 
Heart,  162  ;  abnormal  cardiac  murmurs, 
188;  action  of,  illustration,  168, 
170;  irregularity,  176;  cavitie* 
of,  163;  function  of,  162 ;  rela- 
tions to  chest-wall,   valves  of, 
164;  apex-beat  of,  10 ;  position 
of  impulse.  13,   175;   hypertro- 
phy of,  signs  on  inspection,  17  ; 
impulse  of,  in  emphysema,  16  ; 
physiology  of,  166 ;  rhythm  of, 
169 ;  physical   examination   of, 
171;  boundaries  of,  177 
Heart  diseases — abscess  of,  aneurism  of, 
229;    atrophy    of,    225; 
di.sease  of,  cause  of  pneu- 
monia,   131  ;    dilatation 
of,  222  ;  treatment,  224, 
232;  fatty  degeneration, 
225;    fibroid  disease  of, 
230 ;   functional   disease 
of  235; hypertrophy.  219; 
hypertrophy  and  dilata- 
tion   of,   220 ;    neurosis 
of,  235;  phthisis  of,  225  ; 
rupture  of,  229  ;   syphi- 
litic disease  of,  230;  val- 
vular disease  of.  232 

Heart-sounds.  166  ;  only  one  at  apex  in 
some  cases,  169 ;  causes 
and  character  of,  182  ; 
modifications  by  disease, 
intensity  of,  183 ;  im- 
pure, quality  and  pitch, 
184 ;  seat  and  rhythm, 
metallic  quality,  185  ; 
duration,  reduplication, 
intermission,  186 ;  ab- 
normal, 1 88;  anomalous. 
203 

Helcosis  laryngis,  353 
Heliostat,  271 
Hepatic  dulness  and  flatness,  35 

pulsation,  176 
Herpes  gutteralis,  pharyngis,  herpetic  sore 

throat,  308 
Hippocrates,  28 
Hives  (Rush),  3-M 
Hutchinson,  24 


430 


Hydatids  of  the  lungs,  159 
Hyde,  366 

Hydrothorax,   97;  signs,    17,   20;  differ- 
entiated from   pneumo- 
nia, 125 
Hypenesthesia  of  the  larynx,  384 

of  the  nasal  passages,  411 
of  the  pharynx,  325 
Hyper-sarcosis  cordis,  219 
Hypertrophy  and  dilatation  of  the  heart, 

221 

of  the  heart,  219 
of  the  larynx,  367  [389 

Hysteria,  cause  of  paralysis  -  f  vocal  cords, 

Ice,  sucking  of,  aid  in  laryngoscopy,  282; 

in  rhinoscopy,  288 
Icterus  in  pulmonary  and  cardiac  diseases, 

12 
Illumination    in   laryngoscopy,  260,  263, 

270 

Illuminator,   author's,    Fraenkel's,     266 ; 
Krishaber's,     265  ;      To- 
bold's,  267 
Impulse  of  heart,  area  of,  173;  character 

and  force,  174,  175 
Induration  of  lung,  147,  152 
Inflammatory   lymph,    exudation   of,    on 

pleura,  8l 
Infra  axillary    region,     percussion     signs 

in  health,  36 
Infra-clavicular  region,  percussion  signs 

in  health,  33 
Infra-mammary  region,    percussion  signs 

in  health,  34 
Infra  scapular  region,  percussion  signs  in 

health,  35 

Inhalations  in  bronchitis,  106  ;  vapor, 
416  ;  spray,  418;  dry,  419; 
fuming,  420 

Injections  in  empytema,  94 
Inspection,  9  ;  signs  of  disease,  13-17 
Inspiration  shortened,  59 
Insufflations,  422 
Insufflators,  illustrations,  401 
Intensity  of  percussion  sounds,  29 
Inter-arytenoid  fold,  298 
Intercostal  neuralgia  differentiated   from 
pleurisy,  91 


Interrupted  respiration,  causes,  58 
Inter-scapular  region,  percussion  signs  in 

health,  35 

Interval  between  inspiration   and  expira- 
tion prolonged,  59 

Intra-thoracic  tumors,  solid,  252  ;  differ- 
entiated from  aneurisms, 
247,  248,  249 

Irritative  cough,  382  ;  diagnosis  and  treat- 
ment, 383 

Jaborandi  in  diphtheria,  320 

Jaccoud,  95 

Johnson,  194 

Jugular  veins,  collapse  of,  206 

Kennedy,  225 
Knife-grinder's  rot,  ill 
Knight,  50 
Kramer's  head -band,  246 

Laennec,  46,  61,  68,  141 

Lambron,  322 

Larry,  378 

Laryngeal  and  tracheal  respiration,  54 
cough,  79 

lar.cet.  illustration,  351 
electrodes,  illustrations,  395 

Laryngismus  stridulus,  381  ;  differenti- 
ated from  acute  laryngi- 
tis, 332  ;  from  croup, 

343 

Laryngitis,  acute.  330 
chronic,  337 
erysipelatous,  345 
phlegmonous,   submucosa  pu- 

rulenta,  344 
sub-acute,  334 
syphilitic,  358  ;  illustrations, 

359-  36o 
traumatic,  334 

tuberculous,      353  ;     illustra- 
tions, 354,  355 
Laryngophony,  73 

Laryngoscope,  257  ;  for  common  use, 
269,  271;  cost  of,  272  ; 
mode  of  using,  274 

Laryngoscopic  image,  illustration,  277 
290 


INDEX. 


43' 


Laryngoscopy,   history,    256  ;    the   light, 

259  ;    management    of, 

260  270;    position    of 
patient   and   physician, 
274;  directions  for.  275; 
position      of     patient's 
head,  illustrations,  276, 
277  ;  obstacles  to,  281  ; 
infraglottic.        illustra- 
tions, 285 

Laryngo-tracheal  diphtheria,  341 
Larynx,  alterations  in  disease,  300  ;  dis- 
eases of,  330 ,  anaesthesia  of, 
383;  abscess  of,  illustrations, 
347  ;  effects  on  of  small-pox, 
of  scarlet   fever,  of  measles, 
367;  foreign  bodies  in.  378  ; 
hyperseithesia  of,  384  ;  hyper- 
trophy of,  367;  lupus  of,  illus- 
trations. 365 ;  motor  paralysis 
of.  385;  oedema  of  348  ;  illus- 
trations, 349  ;  spasm  of,  381  ; 
tumors  in,  348 
and  trachea,  stenosis  of,  362 
muscles  and  nerves  of.  385 
normal,   illustrations,  290,   291, 

293,  296    297 

normal,    variations   in   form   of 

different   parts,    illustrations, 

Leared,  48  [293 

Lefferts,  377 

Lenses,   condensing.    260 ;  use   of,    269 ; 

combination  of,  268 

Lepra  of  larynx,  365  ;  illustrations,  366 ; 
differentiated  from  tumors,  372 
Letter  S  curve  in  pleural  effusions,  83 
Levret,  256 

Ligaments  of  larynx,  superior,  295 
Light  for  laryngoscopy,  259,  270  ;  position 
of,  for  laryngoscopy,  275;  losing 
of,  in  laryngoscopy,  by  beginners, 
279;  position  of,  for  rhinoscopy, 
286     ' 
Line  of  flatness,  in  pleurisy,  changed  by 

position,  86 

Lipomata  of  larynx,  371 
Liston,  256 

Liver,  pulsation  of,  176  ;  hypertrophy  of, 
differentiated  from  pleurisy,  93 


Lobular  pneumonia,  135 

Loomis,  38,  170,  209 

Lozenges,  416 

Lung,  collapse  of,  differentiated  from 
pleurisy,  91;  consolidation  of, 
differentiated  from  aneurism, 
249 ;  point  of  perforation  in 
pneumo-thorax,  100 

Lupus  of  larynx,  365  ;  differentiated  from 
tumors,  372 

Mackenzie,  314.  370  ;  his  condenser,  illus- 
tration, 265;  laryngeal  lan- 
cet, illustration,  351  ;  laryn- 
*          geal    dilator,     illustration, 
364  ;    forceps,    illustration, 
375  ;    laryngeal  electrodes, 
illustration,  395 
Mammary   region,    percussion     sign*    in 

health,  34 
Mammillary  line,  6 

Marey's  sphygmograph,  illustration,  207 
Meatus,    superior,  middle,  and  inferior, 

304 

Membranous  sore  throat,  simple,  309 
Mensuration,  21  ;  in  pleurisy,  82 
Mercurials  in  bronchitis,  106 
Mesosternal  line,  7 
Metallic  tinkling.  27,  79,  99 
Miliary  or  acute  tuberculosis,  153 
Mitral   murmurs,   area,    191  ;  regurgitant 
and  obstructive,    192  ;  systolic 
or  regurgitant,    196 ;    curable,. 

202 

regurgitation,      sphygmographic 

tracings,  208 

stenosis,     sphygmographic    trac- 
ings, 210 

Morbid  growths,  in  larynx,  368  ;  angio- 
mata,  cystic  growths,  illustra- 
tions, 371;  fibromata,  fibroma 
of  left  vocal  cord,  illustration, 
fibro-cellular  tumors,  illustra- 
tion, 370 ;  mixed  sarcoma* 
illustration,  371  ;  myomata, 
illustiation,  370;  papillomata, 
illustrations,  369 

Morbus  csenileus,  234 

Morphia  in  asthma,  114 


432 


INDEX. 


Mucous  click,  70   ' 
rales,  67 

"Murmur,  vesicular,  53  ;  muscular,  54 

Murmurs,  c  a  r  d  i  a  c ,  i8S  ;  endocardial, 
causes  of  presystolic,  mitral 
and  tricuspid,  195 ;  mitral, 
systolic,  or  regurgitant,  196  ; 
aortic  systolic,  obstructive  or 
•d  reel,  tricuspid  systolic  or 
regurgitant,  pulmonary  systo- 
lic, obstructive  or  direct, 
197;  aortic  diastolic  or  re- 
gurgitant, pulmonary  diasto- 
lic or  regurgitant,  198;  order 
of  frequency  of  the  various 
murmurs,  199;  subclavian, 
204;  venous,  206 

Muscles   paresis  of,  in  pleurisy,  14 

Myocarditis,  228 

Nasal  abscess,  406 

passages,  foreign  bodies  in,  408 
septum,   distortion   of,    thickening 

of,  405 

speculum,  illustration,  274 
tumors,    mucous     polypi,    fibrous 
tumors,  adenoid  growths,  papil- 
lary growths,  neuromata,  cartila- 
ginous growths,  osteomata,  409 
Neuralgia  of  pharynx,  326  [411 

Neuroses  of  the  nasal  passages,  anosmia, 
^Neurotic    or    functional   disease    of    the 
heart,  325 

Obstacles  to  laryngoscopy,  elongated  uvu- 
la, 281;  irritable  fauces,  382; 
arching  of  the  tongue,  283  ; 
elongated  tonsils,  short  frse- 
num,  283 
CEdema  glottidis,  384 

of  the  larynx,   illustration,  349; 
350;  differentiated  from  chron- 
ic laryngitis,  339 
of  the  lungs,  differentiated  from 

capillary  bronchitis,  io3 
(Edematous  laryngitis,  348 
Opium  in  pneumonia,  126 
Outgrowths  differentiated  from  laryngeal 
tumors,  372 


Pain,  of  aneurism,  241;  in  cancer  of  lar- 
ynx, 373,  374;  in  pleurisy,  82 
Palate  elevator  illustration.  289 
Pallor,  in  pulmonary  and  cardiac  diseases, 

12 
Palpation,  18  ;    in   pleurisy,    82,    83  ;    in 

examination  of  heart,  174 
Palpitation  of  heart  in  aneurisms,  241 
Papillomata  of  larynx,  369 
Parsesthesia  of  pharynx,  325 
Paralysis  of  larynx,    motor,   385;    of   the 
thyro-arytenoid    muscles    and 
partial  para'ysis  of  the  aryte- 
no:d,  388;  bilateral,  of  the  lat- 
eral crico-arytenoid    muscles, 
389  ;    illustrations,   391 ;  uni- 
lateral, of  the  left  crico  aryte- 
no:d  muscle,  illustrations,  391; 
of  the  arytenoid  muscle,  illus- 
tration, 392  ;  bilateral,  of  the 
posterior  crico-arytenoid  mus- 
cles,  il'ustrations,    393  ;   uni- 
lateral, of  the  posterior  crico- 
aryteno  d,  394;  of  the  thyro- 
ep'g'ott'C    and    ary-epiglottic 
muscles,    of   the  crco-thyroid 
muscles,    386 ;    of   the   thyro- 
aryteno'd  muscles,  388 
of  pharynx,  326 
of  the  nostrils,  412 
of  vocal  cords,  333 
Parasternal  lines,  7 

Pectoriloquy,  diseases  heard  in,  77;  \vhis- 

'     pering,  78  ;  aphonic,  79 

Percussion,  med'ate  and  immed;ate,  28  ; 

rules    for,     31  ;    s'gns    in 

health,  33 

in  disease,  38  ;  in  examina- 
tion of  heart,  177 
sounds,  modifications  due  to 
age,  sex  and  idiosyncrasies, 

37 
Pericardial    effusions,    conditions    which 

change  the  area  of  dulness 

in,  i 80 

friction  sounds,  i8£ 
Pericarditis,  212  ;  illustration,  180  ;  pain 

of.  action  of  heart  in,  91 
Pericardium,  162 


INDEX. 


433 


Perichondritis,  laryngeal,  352 
Peripneumonia  and  peripneumonia  vera, 
Pertussis,  145  [120 

Peter,  42,  205 
Pharyngeal  bursa,  illustration,  303 

tonsil,  hypertrophy  of,  403 
Pharyngitis  catarrhalis,  305;  acute  folli- 
cular,  309  ;  chronic,  gran- 
ular herpetic,  or  chronic 
catarrhal,  311;  chronic 
follicular,  illustration, 
312  ;  suppurative,  306 ; 
sicca,  312 

Pharynx,  anaesthesia  of,  hypersesthesia  of, 
parresthes;a  of,  325;  neuralgia 
of,  spasm  of,  paralysis  of,  326 
Phlebectasis  laryngea,  341 
Phlegmonous  laryngitis,  344 

sore  throat,  306 
Phthisis,  infective,  154 

laryngeal,     353  ;     differentiated 

from  tumors,  372 
pulmonary,  signs  on  inspection, 
16;  rales  in,  66,  68;  differenti- 
ated from  pleurisy,  91;  from 
bronchitis,  105 ;  from  bronchi- 
ectasis,  112;  from  pneumonia, 
125;  from  pulmonary  cancer, 
143;  from  syphilitic  disease 
of  the  lungs,  158;  from  hy- 
datids  of  the  lungs,  160;  the 
various  forms  of  phthisis  dif- 
ferentiated, table,  153 
Physical  diagnosis,  I 

Physiological  action  of  heart,  166;  illus- 
tration, 168 
action    of    the    respiratory 

organs,  52 
Pigeon  breast,  10 
Pigments,  421 

Pilocarpine  in  diphtheria,  320 
Piorry,  28 

Pitch  of  percuss'on  sounds,  30 
Pityriasis  in  phth'sis,  12 
Plastic  bronchitis,  109 
Plessigraph,  42 

Pleura,  effects  of  inflammation  on,  8l 
Pleurisy,  acute  and  sub- acute,  81;   s'gns 
on  inspection,   13;  acute,  il- 


lustration, 71;  signs,  of  first 
stage,  82;    of   second  stage, 
83;  of  third  stage,  87;  treat- 
ment of,  88 
Pleurisy,  bilocular,  96 
chron'c,  90 
circumscribed,  94 
diaphragmatic,  95 
multilocu'ar,  95 
of  the  apex,  94 
sub-acute,  illustrat  on.  89 
various     forms     differentiated 
from  each  other,  96;  differen- 
tiated from  pneumonia,  123; 
from  pu'monary  cancer,  143; 
fluctuation  in,  83;  position  in, 
83  ;  dislocation  of  heart   in, 
rule  for  aspiration  in,  opiates 
in,  88 

Pleurodynia,  tender  points  in,  91 
Plexor  and  pleximeter,  illustration,  28 
Pneumo-hydropericardium,  217 
Pneumo-hydrothorax,  99 ;  sign  on  succus- 

sion,  26,  99 

Pneumonia,  lobar,  acute,  croupous,  sthe- 
nic,    120;   catharrhal,  dis- 
seminated,   chronic,    127; 
chronic  or  interstitial,  13, 
152;     croupous,     chronic, 
147,    152 ;   peculiar  forms 
of,  130 ;  illustration,  121 
signs  of  first  and  second  stages, 
122;  of   third  stage,   123; 
differentiated  from  pleurisy, 
91 ;    from  capillary    bron- 
chitis, 107  ;  lobular  differ- 
entiated   from    pulmonary 
collapse,    129 ;    from    pul- 
monary oedema,  138 
treatment  of,  126,  129 
Pneumothorax,    illustration,     98 ;     usual 
point  of  perforation  of 
lung,   100 ;   differenti- 
ated from  emphysema, 
118 

Posterior  nares,  mode  of  inspecting,  301 
Post-palatine    space,    closure   of,   as  an 
obstacle  to  rhinc- 
scopy,  288 


434 


INDEX. 


Potassium  iodide  in  emphysema,  119  ;  in 

pleurisy,  89 
nitrate  in  asthma,  114 
salts  in  bronchitis,  106 
Poultices   in   bronchitis,    109  ;    in    pneu- 
monia, 126 
Powell,  237 
Praecordial  region,  172 
Presystolic  murmurs,  195 
Processus  vocales,  298 
Progressive  bulbar  paralysis,  327 
Pseudo-apoplexy  as  a  symptom  of  fatty 
degeneration  of  heart, 
226 

Pseudo-membranous  croup,  341 
Pulmonary  apoplexy,  133 
area,  193 

artery,  position  of  166  ;  pulsa- 
tion of,  175  ;  aneurism  of, 
246;  aneurism  of,  differenti- 
ated form  aortic  aneurism, 
249 

cancer,  142 
cavities,  traversed   by  trabec- 

ube,  80 
collapse,    135  ;     differentiated 

from  pneumonia,  124 
congestion,  131 
gangrene,  140 

hemorrhage,  133  ;  rales  in,  68 
murmur,  systolic,  197;  diasto- 

lic,  198 

oedema,    138  ;     rales   in,   68  ; 
differentiated  from  capillary 
bronchitis,  108  ;  from  pneu- 
monia, 124 
phthisis,  147 

resonance,    exaggerated,     dis- 
eases causing,  38 
thrombosis  and  embolism,  134 
Pulsations  of  the  heart,  frequency,  irregu- 
larity, 176 

Pulse,  as  a  sign  of  cardiac  disease,  174 
Pupils,  in  aneurism  of  aorta,  241 
Purring  tremor,  176 
Pyramidal  sinuses,  295 
Pyriform  sinuses,  diseases  of,  328 

Quain,  22 


Quality  of  percussion  sounds,  30 
Quebracho,  fl.  ext.  in  asthma,  114 
Quinine,  in  bronchitis,  105  ;  in  pneumo- 
nia, 126 
Quinsy,  306,  320 

Radial    pulse,    normal    sphygmographic 

tracings,  207 
Radiant  point,  262 
Rarefied  air  in  emphysema,  119 
Rales,  rhonchi  or  rattles,  65;  illustration, 

67 

Rappaner's  brush-holder,  illustration,  340 
Rasping  friction  sounds.  71 
Recessus  pharyngei,  303 
Reduplications  of  heart  sounds,  186 
Reflector,  position  of,  in  laryngoscopy,  275 
Reflectors,  concave,  proper  focal  distance 
of,    perforated,    261  ;    mode 
of    determining    focal    dis- 
tance,  means    for   holding, 
263 

Regions,  thoracic,  2  ;  and  contents,  supra- 
clavicular  and  clavicular,  4  ; 
infra-clavicular  and  mammary, 

5  ;     infra-mammary,     supra- 
sternal,  and  superior  sternal, 

6  ;  inferior  sternal,  supra-sca- 
pular,   scapular,   intra-scapu- 
lar,  axillary  and  infra-axillary, 
8 

Resistance,  sense  of,  on  percussion,  29 
Resonance,  causes,  diminished  by,  75  ; 
exaggerated  in  capillary 
bronchitis,  107  ;  tympani- 
tic,  in  pleuritic  effusion, 
86,87 

Respiration,  catching,  13  ;  in  pleurisy,  8 2  ; 
feeble,  57  ;  frequency  of, 
10  ;  amphoric,  63  ;  bron- 
chial, 55,  61  ;  broncho- 
cavernous,  and  cavernous, 
62  ;  rude,  broncho-vesicu- 
lar or  harsh,  60  ;  exagger- 
ated, 56  ;  interrupted,  58  ; 
laryngeal  and  t  radical, 
54 ;  interval  prolonged, 
inspiration  shortened,  ex- 
piration deferred,  59 ; 


INDEX. 


43S 


rude,  60  ;  suppressed,  58  ; 
of  muscular  subjects, 
modified  vesicular  mur- 
mur, 54 

Respiratory  organs,  physiological  action 
of,  52 

Retching  in  laryngoscopy,  produced  by, 
279  ;  prevention  of,  280 

Rheumatic  sore  throat,  308 

Rhinitis,  acute,  398 

Rhinorrhrea,  chronic,  399 

Rhinoscope,  illustration,  273,  289 

Rhinoscopic  yiew  of  vegeta  ions  at  the 
vault  of  pharynx,  illustra- 
tion, 403 

Rhinoscopy,  273,  286  ;  illustration,  286, 
301  ;  obstacles  to  :  closure 
of  the  post-palatine  space, 
•  elongated  uvula,  irritabil- 
ity of  the  fauces,  irritabil- 
ity of  the  tongue,  287 

Rhonchial  fremitus,  20 

Rose  cold,  397 

Rosenmueller,  fossa  of,  303 

Rotch,  214 

Rude  respiration,  causes,  60 

Rupture  of  the  heart,  229 

Sacculus  laryngis,  296 

Sanderson,  210 

Sansom,  234 

Sarcomata  of  larynx,  fasciculated,  371 

Scapular  region,  percussion  signs  in 
health,  35 

Schroetter,  his  method  of  dilating  steno- 
sis of  the  larynx,  351,  363  ; 
his  head-band,  illustration, 
264 

Scirrhus  of  the  lung.  152 

Scissors  for  amputating  the  uvula,  illus- 
tration, 281 

Scrofulous  sore  throat,  314 

Secondary  diseases  of  the  larynx,  367 

Seiler,  298  ;  his  forceps,  376 

Semeleder,  263 

Senile  pulse,  sphygmographic  tracings, 
210 

Septum  narium,  302  ;  distortion  of.  4°5  I 
thickening  of,  405 


Sibilant  rales,  66 

Sinuses  of  Valsalva,  aneurism  of,  239 

laryngo-pharyngeal,  pyramidal  or 

pyriform.  295 
Skin,  appearance  of,   in  pulmonary  and 

cardiac  diseases,  12 

Skoda's  theory  of  bronchial  respiration,  61 
Sonorous  rales.  66 

Sore  throat,  acute,  305  ;  tuberculous,  315  ; 
clergyman's,  catarrhal,  311;  ery- 
sipelatous,  307 ;  membranous, 
308  ;  phlegmonous,  306  ;  rheuma- 
tic, diagnosis  and  treatment.  308  ; 
scrofulous.  314,  316;  syphilitic, 
317  ;  ulcerated,  311 
Sounds,  elements  of  the  percussion,  29 ; 

creaking  or  crumpling,  72 
Spasm  of  glottis,  381  ;  of  pharynx,  326 

of  the  larynx,  381 
Spasmodic  cough,  383 
croup.  381 
Sphygmograph,  206 
Sphygmographic     tracings,     illustrations, 

207,  211 

Spine,  curvature  of,  in  pleurisy,  13 
Spirometer,  Hutchinson's,  illustration,  24 
Spleen,  size  of  dull  area,  36  ;  hypertrophy 
of,  differentiated  from  pleurisy, 

93 

Spray  producer.  401 
Stenosis  of  the  larynx  and  trachea,  362 

of  the  nasal  passages,  407 
Sternal  regions,  percussion  signs  in  health, 

35 
Stethogoniometer,  Allison's,  illustration, 

\  24 

Stethometers,  Quain's  and  Carroll's,  illus- 
trations, 22 

Stethoscopes.  44.  48,  49.  50 
Stoerk's  forceps,  376 
Stokes,  227 

Strychnia  in  bronchitis,  109  ;  in  pneumo- 
nia, 126 

Subclavian  murmurs,  204 
Subcrepitant  rales,  68 
Submucous  laryngitis,  344,  348 
Succussion,  26 ;  in  pneumo-hydrothorax, 

99 

Suffocative  laryngismus.  381 


436 

Suppressed  respiration,  causes,  58 
Supra-clavicular  region,  percussion   signs 

in  health,  33 

Syphilitic  affection  of  the  nares,  406 
disease  of  the  heart,  230 
disease  of  the  lungs,  72  ;  differ- 
entiated from  phthisis,  table, 
diagnosis,  and  treatment.  158 
laryngitis,    358 ;     differentiated 
from   tuberculous    laryngitis, 
356.  358  ;  from  chronic  laryn- 
gitis, 339  ;  from  cancer  of  the 
larynx,    table,   361  ;    illustra- 
tions, 359,  360 
sore  throat,  primary,  secondary, 

tertiary,  317 
Systole  of  heart,  166 
Systolic  murmurs,  196 

Telescope  for  laryngoscopy,  271 
Thompson,  38,  72,  118,  134 
Throat  consumption,  353 

mirror,  257 ;  illustration,  258 ; 
concave,  271  ,  management  of, 
warming  of,  275,  280 ;  mirror, 
position  in  rhinoscopy,  287 ; 
mirror  and  tongue  depressor 
combined,  288 

Tobold's  illuminator,  illustration,  267 
Tongue  depressors,  illustrations,  255 

irritability  of,  as  obstacle  to  rhi- 
noscopy, 287  ;  manner  of  hold- 
ing. 275,  277  ;  swallowing  of, 
328 
Tonsil,  concretions  in,  323  ;  hypertrophy 

of,  322 

Tonsilla  pharyngeus,  304 
Tonsillitis,    acute    and    follicular,    321  ; 
chronic,    322  ;     depression 
of  chest-walls  in,  322 
Trachea,  bifurcation  of,  distance  from  re- 
flector, 260 
illustrations,  299 
involution     of,     378  ;      foreign 

bodies  in,  379 
tumors  of,  377 
Tracheal  cartilage*,  298 

mucous  membrane,  298 
respiration,  54 


INDEX. 


Tracheitis,  351 

Tracheocele,  378 

Tracheophony,  73 

Trachoma  of  the  vocal  cords,  341 

Traube,  86 

Triangle  of  dulness  in  pleurisy,  85 

Tricuspid  murmurs,  area,  193  ;  systolic 
or  regurgitant,  197  ;  regur- 
gitation  in  emphysema,  117 

Trochisci  416 
Trousseau,  43,  256 

Tuberculosis,  acute,  153  ;  mucous  click 
in,  70;  'differentiated 
from  emphysema,  118 ; 
chronic,  147 

Tuberculous   laryngitis,     353  ;     illustra- 
tions, 354.  355  ;   differen- 
tiated from  chronic  laryn- 
gitis, 339 
sore  throat,  315 
Tubular  resonance,  occassionally  obtained 

in  pneumonia,  122 
Tufnell,  250 
Tumors  of  larynx,    369  ;   nasal,  409  ;   of 

the  lungs,  141 
of  trachea,  illustration,  377 
solid   intra-thoracic,    252  ;    s:gns 
of,  17,  20,   252  ;  differentiated 
from  aneurisms,  247 
Turbinated  bones,  302 
Tlirck,  257,  271 
Tussive  signs,  79 

Tympanitic  resonance,  diseases  causing 
it,  40  ;  in  pleurisy,  86  ; 
in  pneumothorax.  99 

Ulcerative  endocard'tis.  231 

Uvu'a,  means  of  e'evating  it,  279  ;  elong- 
ated, management  of,  281  ;  as 
an  obstac'e  to  rhinoscopy,  288 

Valecu'se.  293  ;  d-seases  of,  328 
Valves,  cardiac  position  of,  165 
Valvular  diseases  of  the  heart,  treatment, 
232 

sounds  of  heart,  166 
Vault  of  the  pharynx  and  nasal  cavities 

in  health,  300  ;   adenoid  tissue, 

illustration,  303 


INDEX. 


Vegetations  at  vau't  of  pharynx,  illustra- 
tion, 403  • 

Veins  of  the  neck  and  upper  part  of  the 
trunk,    temporary     turgescence, 
cause  of,  204 
pulsation   of,    on   back   of  hands, 

205  ;  jugu'ar,  collapse  of,  206 
Venous  conge-tion,  204 
murmurs,  206 
pulsation   as   a    s'gn    of    cardiac 

disease,  171,  205 
Ventric'e,  eversion  of,  d  fferent'ated  from 

laryngea!  tumors,  372 
of  larynx,  296 
Ventr'cular  bands,  295 

murmurs,  different'ated  from, 
mitral  regurgitant  aortic 
and  pulmonary  murmurs, 
199,  201 

Veratrum  in  pneumonia,  126 
Vesicular  murmur,  53  ;  normal  modifica- 
tions of,  54  ;  suppressed,  103 
Vesiculo-tympanitic    resonance,    diseases 
causing  it,  41  ;  in  pleurisy,  83 
Virchow,  231 
Vision,  disordered,  in  aneurism  of  aorta, 

241 

Vocal  cords  and  glottis,  296 
cords,  false,  295 
cords,  paralysis  of,  386  to  392 


Vocal  cords,    resp  ratory   movements  of, 

297  ;  atrophy  of,  396 
frem  tus,  norma',  d  seases  in  which 
a'tered,  19  ;  in  pleurisy,  82  ;  in 
emphysema,  116 
processes.  298 
resonance,    var'et  es,    73;    normal, 

74;  a'tered  in  disease,  75 
signs,  73 

sounds  classified,  75 
Vo!to;in>,  271;  h  s  staff,  284 
Vomer,  submucus  infiltration  at  the  s'des 
of,  illustration,  404 

Warden,  256 

Weil,  267 

Wertheim,  271 

Whisper,  amphoric,  cavernous,  exagger- 
ated, bronchial,  normal  bron- 
chial, 78 

Whispering  pectoriloquy,  78 

vocal  resonance,  78 

Whistler's  method  of  dilating  stenosis  of 

Whooping  cough,  145  [larynx,  362 

Wintrich,  86,  95 

Yeo,  94 

Ziemssen's  double  and  single  electrodes^ 
illustration,  395 


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IX  SOUTHERN  REGIONAL  UBRAf 


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WF9TO 

I  hkL 

1881 
Ingals,  Ephraim  Fletcher. 

Lectures  on  the  diagnosis  and  treatment 
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